Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

Abstract: Background: During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers. Methods: A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence. Results: 31 papers, reporting on 27 studies and published 1985–2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised. Conclusion: Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use

Managing patient deterioration: a protocol for enhancing undergraduate nursing students' competence through web-based simulation and feedback techniques

Aims: To describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.Background: There are international concerns regarding the management of deteriorating patients with issues around the 'failure to rescue'. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.Design/Methods: A mixed methods triangulated convergent design.In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.Conclusion: This project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program

Improving decision-making for sustainable hunting: regulatory mechanisms of hunting pressure in red-legged partridge

Knowledge about how hunting pressure is determined, and the relative efficacy of different mechanisms to regulate harvest, can help to improve the managers’ decision-making process. We developed a general framework about the decision-making process that regulates red-legged partridge (Alectoris rufa) hunting pressure in central Spain based on information from a focus group and individual interviews with game managers. We also used available information to compare the efficiency of different tools thus improving some decision steps. We evaluated the cost-effectiveness of different population monitoring methods as a way to reduce uncertainty on partridge availability to hunters. Additionally, we investigated the relationship between annual harvest and various regulatory mechanisms of partridge hunting pressure used in the study area to identify the most potentially useful one to limit annual take-off. Game managers usually set hunting pressure after a qualitative assessment on population abundance prior to the hunting season, but this decision was frequently modified during the course of the hunting season according to variations in catch or perceived abundance at that time. Our results showed that kilometric abundance indices (counting partridges from cars along line transects) was a simple cost-efficient and reliable estimate of partridge density (estimated by Distance sampling). A variety of regulatory mechanisms were used by managers. The variables that most affected annual harvest (in addition to partridge abundance) were the number of driven-shooting days, and hunter density in walked-up hunting days, suggesting that their adjustment will be the most efficient regulatory mechanisms. We conclude that adequate monitoring on population abundance should be a critical step for managers’ decision-making, and that a better understanding of the relative value of regulatory mechanisms, combining social and ecological approaches, would help improving our understanding of any human-mediated system, thus leading to better management recommendations.Work was supported by the European Commission (7th Framework Programme for R&D through project HUNT, 212160, FP7-ENV-2007-1); Consejería de Agricultura of JCCM; by the Ministerio de Ciencia y Tecnología (CGL2008-04282/BOS), and by CSIC (PIE 201330E105).Peer reviewe

Integrating Endocannabinoid Signaling and Cannabinoids into the Biology and Treatment of Posttraumatic Stress Disorder

Exposure to stress is an undeniable, but in most cases surmountable, part of life. However, in certain individuals, exposure to severe or cumulative stressors can lead to an array of pathological conditions including posttraumatic stress disorder (PTSD), characterized by debilitating trauma-related intrusive thoughts, avoidance behaviors, hyperarousal, as well as depressed mood and anxiety. In the context of the rapidly changing political and legal landscape surrounding use of cannabis products in the United States, there has been a surge of public and research interest in the role of cannabinoids in the regulation of stress-related biological processes and in their potential therapeutic application for stress-related psychopathology. Here we review the current state of knowledge regarding the effects of cannabis and cannabinoids in PTSD and the preclinical and clinical literature on the effects of cannabinoids and endogenous cannabinoid signaling systems in the regulation of biological processes related to the pathogenesis of PTSD. Potential therapeutic implications of the reviewed literature are also discussed. Lastly, we propose that a state of endocannabinoid deficiency could represent a stress-susceptibility endophenotype predisposing to the development of trauma-related psychopathology and provide biologically plausible support for the self-medication hypotheses used to explain high rates of cannabis use in patients with trauma-related disorders.Neuropsychopharmacology accepted article preview online, 26 July 2017. doi:10.1038/npp.2017.162