Skills to facilitate learning in clinical practice

Midwifery Basics: Mentorship 2 Mentorship is the 14th series of 'Midwifery basics' targeted at practising midwives. The aim of these articles is to provide information to raise awareness of the impact of the work of midwives on women's experience, and encourage midwives to seek further information through a series of activities relating to the topic. In this second article Jayne Samples and Joyce Marshall consider some of the key issues that can affect student learning in clinical practice

Thinking through Making

A discussion of the relationship between making and thinking through documenting a visit to a potter and ceramicist based in Goa, India. It includes making distinctions between a designerly and crafty approach to the development of artifacts

Informed consent during the intrapartum period: an observational study of the interactions between health professionals and women in labour involving consent to procedures

This ethnographic study using participant observation, aimed to explore the issue of informed consent to procedures undertaken during the intrapartum period. It involved recruiting 100 healthy women, who went into labour spontaneously at term, at the point they were admitted to the labour ward. The data collection took place in a large teaching hospital in an East Midlands city from April 1997 until December 1999. The subjects (health professionals and women) were observed throughout the labour until the woman and baby were transferred to the postnatal area. Follow-up interviews were conducted with the woman and midwives, within 24 hours, using a semi-structured format based on the observations. The study revealed that it was difficult to obtain informed consent during labour. Contrary to professional belief, not all women wanted to be fully informed about intrapartum care and procedures, or wanted anything other than a pain free and easy labour that they perceived the western medical-technocratic model of care would offer them. Although the midwives' knowledge of legal and ethical issues concerning consent was variable and limited in the majority of cases, they attempted to empower women to make intrapartum choices. However, this was often constrained by the culture of the labour ward environment and the extent to which they adhered to policies and procedures. In cases where medical intervention became necessary, a minority of midwives felt personally disempowered. The obstetricians and paediatricians observed, appeared to be less effective communicators than anaesthetists, often leaving it to the midwife to explain issues to the woman. It is envisaged that these findings, as well as the stereotypical models of the labouring woman and the attending midwife that developed, and the resulting recommendations, be used in partnership between maternity service and education providers to ensure that health professionals not only have effective communication and interpersonal skills, but also are more conversant with the legal and ethical implications of consent

Perinatal/neonatal palliative care : effecting improved knowledge and multi-professional practice of midwifery and children's nursing students through an inter-professional education initiative

This paper presents a study that examines the potential value of a new and innovative inter-professional education (IPE) experience for final year midwifery and children's nursing students focused on improving awareness of end-of-life care for infants in conjunction with the support of their families. The study uses an action research approach to examine midwifery and children's nursing student experiences of an IPE initiative in developing knowledge regarding perinatal/neonatal palliative care. // The setting is a Higher Education Institute in the South of England that included final year midwifery students (n = 39) and children's nursing students (n = 34) taking part in the study. Qualitative and quantitative data indicated that the IPE intervention had proven worth in developing knowledge and confidence in the students as both student groupings felt they lacked knowledge and confidence about perinatal/neonatal palliative care before attending the study day. // Students felt that learning with, from and about the other profession represented was important in generating their knowledge. Educators should explore innovative ways to enable the further development of the fledgling speciality of perinatal/neonatal palliative care through education on an interprofessional platform

Exploring and adjusting for potential learning effects in ROLARR: a randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection

Background: Commonly in surgical randomised controlled trials (RCT) the experimental treatment is a relatively new technique which the surgeons may still be learning, while the control is a well-established standard. This can lead to biased comparisons between treatments. In this paper we discuss the implementation of approaches for addressing this issue in the ROLARR trial, and points of consideration for future surgical trials. Methods: ROLARR was an international, randomised, parallel-group trial comparing robotic vs. laparoscopic surgery for the curative treatment of rectal cancer. The primary endpoint was conversion to open surgery (binary). A surgeon inclusion criterion mandating a minimum level of experience in each technique was incorporated. Additionally, surgeon self-reported data were collected periodically throughout the trial to capture the level of experience of every participating surgeon. Multi-level logistic regression adjusting for operating surgeon as a random effect is used to estimate the odds ratio for conversion to open surgery between the treatment groups. We present and contrast the results from the primary analysis, which did not account for learning effects, and a sensitivity analysis which did. Results: The primary analysis yields an estimated odds ratio (robotic/laparoscopic) of 0.614 (95% CI 0.311, 1.211; p = 0.16), providing insufficient evidence to conclude superiority of robotic surgery compared to laparoscopic in terms of the risk of conversion to open. The sensitivity analysis reveals that while participating surgeons in ROLARR were expert at laparoscopic surgery, some, if not all, were still learning robotic surgery. The treatment-effect odds ratio decreases by a factor of 0.341 (95% CI 0.121, 0.960; p = 0.042) per unit increase in log-number of previous robotic operations performed by the operating surgeon. The odds ratio for a patient whose operating surgeon has the mean experience level in ROLARR – 152.46 previous laparoscopic, 67.93 previous robotic operations – is 0.40 (95% CI 0.168, 0.953; p = 0.039). Conclusions: In this paper we have demonstrated the implementation of approaches for accounting for learning in a practical example of a surgery RCT analysis. The results demonstrate the value of implementing such approaches, since we have shown that without them the ROLARR analysis would indeed have been confounded by the learning effects

Crafting the Digital

When Irini Papadimitriou asked us to write a reflective piece on crafting the digital that drew on the activities and content of this publication we decided to take an open ended, and perhaps somewhat wandering approach. An approach that mingled thoughts from personal interests and experiences as much as from our professional practice. An approach that wanders between the practicalities of approaching the creation of objects from a pre-industrial production stance to the sensitivities of crafting objects in relation to people and the complex messy lives they lead. We wanted to give our view on the ways in which the methods and mindsets of craft can provide a new perspective on the future of digital and the expectations, hopes and aspirations we have for it. We’re Justin Marshall a Digital Craftsperson, Jon Rogers a Creative Technologist and Jayne Wallace a Digital Jeweller

Making makes me feel better: Designing for wellbeing and social values

This paper presents a design-led inquiry, which aimed to explore the benefits on wellbeing for people living with early stage dementia through participatory handcraft workshops. The project took place in a historically immersive environment at an open air living history museum involving a dementia friendly design team consisting of researchers, museum staff, volunteers and people living with dementia. Drawing on historic themes from the museum collections a range of new co-produced items were sold in the museum gift shop. The workshop activities enabled an understanding to be established of living with dementia, the value of making and the abilities of people with dementia. Through the experiences of this small group we unpick the rich detail of the participatory activities in terms of wellbeing. Valuing the contribution of each individual and working side by side we really got to know personalities by observing the nuances of body language, recognising abilities and shifts in confidence. We draw out the value of being ‘in the moment’ and also ‘significant moments of realisation’. Often the participants commented that concentrating on a creative activity in the moment could be absorbing, the close connection with materials was shown to be comforting. We observed a commitment and ownership of the project and increased levels of confidence in participants where they valued learning new skills and felt privileged to work and have access to the historic collections within the museum. The co-design project received positive feedback from the local community and visitor interest through sales. Through the project we sought to support the voice of people with dementia as one participant put it: ‘The trouble is you see, when you’re working everything is fast, you don’t have time to try new things and we’re not in a hurry, making makes me feel better.’ Participan

On dynamically consistent eddy fluxes

Author Posting. © The Author, 2004. This is the author's version of the work. It is posted here by permission of Elsevier B. V. for personal use, not for redistribution. The definitive version was published in Dynamics of Atmospheres and Oceans 38 (2005): 123-146, doi:10.1016/j.dynatmoce.2004.11.003.The role of mesoscale oceanic eddies in driving the large-scale currents is studied in an eddy-resolving, double-gyre ocean model. The new diagnostic method is proposed, which is based on dynamical decomposition of the flow into the large-scale and eddy components. The method yields the time history of the eddy forcing, which can be used as additional, external forcing in the corresponding non-eddy-resolving model of the gyres. The main strength of this approach is in its dynamical consistency: the non-eddy-resolving solution driven by the eddy forcing history correctly approximates the original large-scale flow component. It is shown that statistical decompositions, which are based on space-time filtering diagnostics, are dynamically inconsistent. The diagnostics algorithm is formulated and tested, and the diagnosed eddies are analysed, both statistically and dynamically. It is argued that the main dynamic role of the eddies is to maintain the eastward-jet extension of the subtropical western boundary current (WBC). This is done largely by both the time–mean isopycnal-thickness flux and the relative-vorticity eddy flux fluctuations. The fluctuations drive large-scale flow through the nonlinear rectification mechanism. The relative-vorticity flux contributes mostly to the eastward jet meandering. Finally, eddy fluxes driven by both the eddies and the large-scale flow are found to be important. The latter is typically neglected in the analysis, but here it corresponds to important large-scale feedback on the eddies.Funding for this research was provided by NSF grant OCE 00–91836, by the Royal Society Fellowship, and by WHOI grants 27100056 and 52990035

Robotic-assisted surgery compared with laparoscopic resection surgery for rectal cancer: the ROLARR RCT

This is the final version. Available from NIHR Journals Library via the DOI in this recordData-sharing statement: All available data can be obtained by contacting the corresponding author.Background Robotic rectal cancer surgery is gaining popularity, but there are limited data about its safety and efficacy. Objective To undertake an evaluation of robotic compared with laparoscopic rectal cancer surgery to determine its safety, efficacy and cost-effectiveness. Design This was a multicentre, randomised trial comparing robotic with laparoscopic rectal resection in patients with rectal adenocarcinoma. Setting The study was conducted at 26 sites across 10 countries and involved 40 surgeons. Participants The study involved 471 patients with rectal adenocarcinoma. Recruitment took place from 7 January 2011 to 30 September 2014 with final follow-up on 16 June 2015. Interventions Robotic and laparoscopic rectal cancer resections were performed by high anterior resection, low anterior resection or abdominoperineal resection. There were 237 patients randomised to robotic and 234 to laparoscopic surgery. Follow-up was at 30 days, at 6 months and annually until 3 years after surgery. Main outcome measures The primary outcome was conversion to laparotomy. Secondary end points included intra- and postoperative complications, pathological outcomes, quality of life (QoL) [measured using the Short Form questionnaire-36 items version 2 (SF-36v2) and the Multidimensional Fatigue Inventory-20 (MFI-20)], bladder and sexual dysfunction [measured using the International Prostatic Symptom Score (I-PSS), the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI)], and oncological outcomes. An economic evaluation considered the costs of robotic and laparoscopic surgery, including primary and secondary care costs up to 6 months post operation. Results Among 471 randomised patients [mean age 64.9 years, standard deviation (SD) 11.0 years; 320 (67.9%) men], 466 (98.9%) patients completed the study. Data were analysed on an intention-to-treat basis. The overall rate of conversion to laparotomy was 10.1% and occurred in 19 (8.1%) patients in the robotic-assisted group and in 28 (12.2%) patients in the conventional laparoscopic group {unadjusted risk difference 4.12% [95% confidence interval (CI) –1.35% to 9.59%], adjusted odds ratio 0.61 [95% CI 0.31 to –1.21]; p = 0.16}. Of the nine prespecified secondary end points, including circumferential resection margin positivity, intraoperative complications, postoperative complications, plane of surgery, 30-day mortality and bladder and sexual dysfunction, none showed a statistically significant difference between the groups. No difference between the treatment groups was observed for longer-term outcomes, disease-free and overall survival (OS). Males were at a greater risk of local recurrence than females and had worse OS rates. The costs of robotic and laparoscopic surgery, excluding capital costs, were £11,853 (SD £2940) and £10,874 (SD £2676) respectively. Conclusions There is insufficient evidence to conclude that robotic rectal surgery compared with laparoscopic rectal surgery reduces the risk of conversion to laparotomy. There were no statistically significant differences in resection margin positivity, complication rates or QoL at 6 months between the treatment groups. Robotic rectal cancer surgery was on average £980 more expensive than laparoscopic surgery, even when the acquisition and maintenance costs for the robot were excluded. Future work The lower rate of conversion to laparotomy in males undergoing robotic rectal cancer surgery deserves further investigation. The introduction of new robotic systems into the market may alter the cost-effectiveness of robotic rectal cancer surgery.National Institute for Health Research (NIHR