8/31/2020 0 Comments Care model comparison & IDACare Model Comparison I will firstly describe two of the models of care available to women at this health service: the maternity group practice (MGP) and general practitioner (GP) shared care. I will then compare these options using evidence-based material to support her making an informed choice 1,2. MGP, also known as caseload midwifery, is a maternity model where all pregnancy, birth and postnatal care are provided by a primary midwife with the assistance of a backup or secondary midwife 1. GP shared care is a collaboration between a qualified community GP and the local hospital. The GP sees the woman for most of the antenatal care with selected appointments and the birth taking place at the nominated hospital with shift midwives 3. Under MGP, midwives are trained to support and be attuned to the normal physiological processes of pregnancy, birth and breastfeeding and can detect deviations from this 4. This model enables care and support by a known midwife in a continuity of care approach. It has decreased rates of instrumental birth, episiotomy, regional analgesia use, and amniotomy, and higher rate of spontaneous vaginal birth 5,6. It also has higher incidences of water immersion, physiological third stage, second-degree tears 6, longer labours and less likelihood of adverse fetal and neonatal outcomes 5. It is therefore not surprising that this mode of care is in high demand and consequently can be difficult to access 3. A more accessible choice is the GP shared care model offering some continuity of care, especially in the broader lifespan context. With this model the woman can choose their general practitioner who can offer convenience in location and access to appointments, as well as offer more culturally and language appropriate choices 7. However, GPs need to complete extra specialist training in maternity care to offer this option 8 and are often not equipped to offer satisfactory breastfeeding and nutritional information 9,10. Both models cover the standard pre-, post- and intra-partum care through public funding 1. They offer intrapartum care in a local hospital predominantly supported by midwives and they both adhere to timely consultation and referral guidelines 11. The GP program reports positive satisfaction levels 9, but the outcomes for babies and maternal satisfaction rate is higher in MGP models than in standard care, including GP shared care 5,12. Satisfaction also comes when a woman feels she has sufficient information to choose a model of maternity care 13. These two options would give her a choice of continuity of care led by midwives with higher rates of normal physiological birth or familiarity of care with her own general practitioner. Offering a woman informed choice typically enables collaboration and the right to autonomy and self-determination. Iron Deficiency Anamia Case Study I will describe how therapeutic information will be provided within a midwifery group practice model of care to a woman found to have iron deficiency anaemia, and how care will be planned in partnership with her relating to this. As early antenatal care providers, group practice midwives are in an important position to identify anaemia in pregnant women, determine the underlying causes and guide best choice management of the condition 14. Iron deficiency anaemia (IDA) is characterised by a haemoglobin level below 110 g/L in the first and third trimesters or below 105 g/L in the second trimester 15,16, along with a serum ferritin level less than 30 μg/L 17. In this woman’s case, her ferritin levels were under 15 μg/L which indicated iron depletion 18. After review, the midwife can discuss the results with the woman at her next antenatal visit 19. This can include explaining that iron is required to transport oxygen around our body and that these levels can drop in pregnancy due to increased blood volume and demand, but that her results were outside of what would be expected. In order to provide quality continuity of care, this woman’s whole clinical story needs to be considered to make suitable recommendations 20. Firstly, this can done by asking how she is feeling and validating any linked common symptoms such as general fatigue, weakness and depression 21. Assessing her health literacy around the diagnosis and ensuring she comprehends what these results mean is important 22. The midwife can invite the woman to express what she understands and provide more or clearer information if necessary. When this understanding is established, the midwife can also explain how low iron levels are linked to premature and small babies, increased infection, birth complications and ante- and post-natal depression 15. The midwife can revisit the woman’s current nutrition and supplement intake and can offer a recommendation 24 to consume more lean red meat, eggs and chicken. Other great iron-rich foods to recommend, especially if the woman does not eat animal products, are fermented wholegrain foods, fortified cereals, dried fruit, roasted nuts, seeds, green leafy vegetables, blackstrap molasses, Marmite, Vegemite and soaked legumes 25. To assist in iron absorption, food rich in vitamin-C can also be added to this list, such as citrus fruits, kiwifruit and broccoli 25. The midwife can also recommend limiting the intake of calcium, zinc, black tea, and red wine in conjunction with iron intake; these substances can inhibit iron uptake into the body 25,15. It is unlikely that diet alone can offer improvements given the woman’s circulating and stored iron levels and reasonably common for midwives practicing continuity of care to prescribe supplementation 26. It is recommended that she commence oral iron supplementation of 100 mg as a first line treatment to be taken separately instead of in a multivitamin. This recommendation can be offered while encouraging the woman to ask questions to make a fully informed decision about taking them. Some of this conversation can include sharing the side effects and hazards of the supplements and how to minimise their effect. Side effects include constipation, diarrhoea, nausea and vomiting 27 with hazards of a raised haemoglobin risking placental insufficiency and secondary haemochromatosis 28. Recommendations to increase tolerance would include taking them at bedtime, with food that does not decrease absorption and lowering the dose or frequency 15,29. It is also worth considering and discussing what other barriers the woman may have in obtaining and taking the supplements and consuming iron-rich foods, such as financial, logistical or cultural difficulties. The midwife can document the information and offer a plan to the woman in light of this diagnosis and discussion. It is anticipated that her haemoglobin levels should increase by about 10-20 g/L over the next three to four weeks while taking the supplements 30. This plan would include retesting in about two weeks 14 and again at 36 weeks gestation 19. If the follow-up blood tests do not show expected improvements, intravenous iron supplementation should be offered 14. If any tests show her haemoglobin level has dropped below 90 g/L, the midwife should seek consultation with a medial practitioner 31. All this clinical information can be conveyed to the woman at the appropriate times as their relationship is built. Through close investigation of the journey of this woman’s IDA diagnosis, it is clear to see the benefits of continuity of care in ensuring safe, evidence-based, woman-centred midwifery care. This has been achieved with holistic, therapeutic communication of the relevant information with key decisions made in close partnership with the woman and the MGP midwife. References (1) COAG Health Council. Woman-Centred Care: Strategic Directions for Australian Maternity Services. Department of Health August 2019. (2) International Confederation of Midwives. International Code of Ethics for Midwives. (3) Homer, C. S. Models of Maternity Care: Evidence for Midwifery Continuity of Care. Med. J. Aust. 2016, 205 (8), 370–374. https://doi.org/10.5694/mja16.00844. (4) Frye, A. Holistic Midwifery: A Comprehensive Textbook for Midwives in Homebirth Practice; Labrys Press: Portland, Or. (7528 NE Oregon St., Portland 97213), 1995. (5) Sandall, J.; Soltani, H.; Gates, S.; Shennan, A.; Devane, D. Midwife-Led Continuity Models versus Other Models of Care for Childbearing Women. Cochrane Database Syst. Rev. 2016. https://doi.org/10.1002/14651858.CD004667.pub5. (6) Gidaszewski, B.; Khajehei, M.; Gibbs, E.; Chua, S. C. Comparison of the Effect of Caseload Midwifery Program and Standard Midwifery-Led Care on Primiparous Birth Outcomes: A Retrospective Cohort Matching Study. Midwifery2019, 69, 10–16. https://doi.org/10.1016/j.midw.2018.10.010. (7) Better Health Channel. Pregnancy and birth care options https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/pregnancy-and-birth-care-options (accessed Aug 15, 2020). (8) Conjoint Committee; CCDOG. Shared Maternity Care Obstetric Patients; Conjoint Committee for the Diploma of Obstetrics and Gynaecology, 2016. (9) Lucas, C.; Charlton, K.; Brown, L.; Brock, E.; Cummins, L. Review of Patient Satisfaction with Services Provided by General Practitioners in an Antenatal Shared Care Program. 2015, 5. (10) Walker, R.; Choi, T. S. T.; Alexander, K.; Mazza, D.; Truby, H. ‘Weighty Issues’ in GP-Led Antenatal Care: A Qualitative Study. BMC Fam. Pract. 2019, 20 (1), 148. https://doi.org/10.1186/s12875-019-1026-4. (11) Women’s Health Committee. Maternal Suitability for Models of Care, and Indications for Referral within and between Models of Care. The Royal Austraian and New Zealand College of Obstetricians and Gynaecologists March 2018. (12) Forster, D. A.; McLachlan, H. L.; Davey, M.-A.; Biro, M. A.; Farrell, T.; Gold, L.; Flood, M.; Shafiei, T.; Waldenström, U. Continuity of Care by a Primary Midwife (Caseload Midwifery) Increases Women’s Satisfaction with Antenatal, Intrapartum and Postpartum Care: Results from the COSMOS Randomised Controlled Trial. BMC Pregnancy Childbirth 2016, 16 (1), 28. https://doi.org/10.1186/s12884-016-0798-y. (13) Stevens, G.; Miller, Y. D.; Watson, B.; Thompson, R. Choosing a Model of Maternity Care: Decision Support Needs of Australian Women. Birth 2016, 43 (2), 167–175. https://doi.org/10.1111/birt.12212. (14) Frayne, J.; Pinchon, D. Anemia in Pregnancy. Hematol. Oncol. Clin. North Am. 2019, 25 (2), 241–259. https://doi.org/10.1016/j.hoc.2011.02.001. (15) Milman, N.; Paszkowski, T.; Cetin, I.; Castelo-Branco, C. Supplementation during Pregnancy: Beliefs and Science. Gynecol. Endocrinol. 2016, 32 (7), 509–516. https://doi.org/10.3109/09513590.2016.1149161. (16) Daru, J.; Cooper, N. A. M.; Khan, K. S. Systematic Review of Randomized Trials of the Effect of Iron Supplementation on Iron Stores and Oxygen Carrying Capacity in Pregnancy. Acta Obstet. Gynecol. Scand. 2016, 95 (3), 270–279. https://doi.org/10.1111/aogs.12812. (17) RCPA. Iron Studies Standardised Reporting Protocol; The Royal College of Pathologists of Australia, 2013; p 16. (18) Pavord, S.; Myers, B.; Robinson, S.; Allard, S.; Strong, J.; Oppenheimer, C.; on behalf of the British Committee for Standards in Haematology. UK Guidelines on the Management of Iron Deficiency in Pregnancy. Br. J. Haematol.2012, 156 (5), 588–600. https://doi.org/10.1111/j.1365-2141.2011.09012.x. (19) Department of Health. Clinical Practice Guidelines: Pregnancy Care; Australian Government Department of Health: Canberra, 2018. (20) Grigg, C. Working with Women in Pregnancy. In Midwifery : preparation for practice; Elsevier Australia: Chatswood, AUSTRALIA, 2019; p 44. (21) Milman, N. Oral Iron Prophylaxis in Pregnancy: Not Too Little and Not Too Much! J. Pregnancy 2012, 2012, 1–8. https://doi.org/10.1155/2012/514345. (22) Australian Commission on Safety and Quality in Health Care. HEALTH LITERACY: Taking Action to Improve Safety and Quality; ACSQHC: Sydney, 2014. (23) Chatterjee, N.; Fernandes, G. ‘This Is Normal during Pregnancy’: A Qualitative Study of Anaemia-Related Perceptions and Practices among Pregnant Women in Mumbai, India. Midwifery 2014, 30 (3), e56–e63. https://doi.org/10.1016/j.midw.2013.10.012. (24) Chatterjee, R.; Shand, A.; Nassar, N.; Walls, M.; Khambalia, A. Z. Iron Supplement Use in Pregnancy – Are the Right Women Taking the Right Amount? Clin. Nutr. 2016, 35 (3), 741–747. https://doi.org/10.1016/j.clnu.2015.05.014. (25) Wratten, J.; Gibbons, M. Nutrition and Physical Activity Foundations for Pregnancy, Childbirth and Lactation. In Midwifery Preparation for Practice; Pairman, S., Tracy, S. K., Dahlen, H. G., Dixon, L., Eds.; 2019; pp 404–423. (26) Hunter, M.; Davis, D. Pharmacology and Prescribing. In Midwifery Preparation for Practice; Pairman, S., Tracy, S. K., Dahlen, H. G., Dixon, L., Eds.; 2019; pp 707–733. (27) Peña-Rosas, J. P.; De-Regil, L. M.; Dowswell, T.; Viteri, F. E. Daily Oral Iron Supplementation during Pregnancy. In Cochrane Database of Systematic Reviews; The Cochrane Collaboration, Ed.; John Wiley & Sons, Ltd: Chichester, UK, 2012; p CD004736.pub4. https://doi.org/10.1002/14651858.CD004736.pub4. (28) Ribot, B.; Aranda, N.; Giralt, M.; Romeu, M.; Balaguer, A.; Arija, V. Effect of Different Doses of Iron Supplementation during Pregnancy on Maternal and Infant Health. Ann. Hematol. 2013, 92 (2), 221–229. https://doi.org/10.1007/s00277-012-1578-z. (29) Peña-Rosas, J. P.; De-Regil, L. M.; Gomez Malave, H.; Flores-Urrutia, M. C.; Dowswell, T. Intermittent Oral Iron Supplementation during Pregnancy. Cochrane Database Syst. Rev. 2015. https://doi.org/10.1002/14651858.CD009997.pub2. (30) Percy, L.; Mansour, D.; Fraser, I. Iron Deficiency and Iron Deficiency Anaemia in Women. Best Pract. Res. Clin. Obstet. Gynaecol. 2017, 40, 55–67. https://doi.org/10.1016/j.bpobgyn.2016.09.007. (31) Australian College of Midwives Ltd. ACM C&R Guidelines; Australian College of Midwives Ltd.: Apple App store, 2016. it. marked: 72/100
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Midwives are primary carers in our health system providing primary maternity care which is grounded in evidence-based maternal health care and is centred around the woman [1]. This essay will discuss how primary care and primary health care differ and how primary health care provided by midwives contributes to healthy outcomes for women and their babies. Firstly, it will define and address the differences between primary care and primary health care. Next, it will explain how midwives work as primary health care providers and finally it will present how midwifery-led primary health care contributes to healthy maternal and neonate outcomes. It is incorrect to use the terms ‘primary care’ and ‘primary health care’ as if they are interchangeable and this is why clear definitions are important [2]. Primary care is a therapeutic service delivered in the community that is often a person’s entry point into a medical system focussed on illness diagnosis, treatment and/or referral [3]. The primary carer is the initial practitioner and has the greatest responsibility and can include general practitioners, pharmacies, allied and community health providers and midwives [4]. The term ‘primary health care’ is predominantly used to refer to a public health philosophy that provides essential, consumer acceptable healthcare services to the greater population that are equitably accessible to individuals, families and the community [3]. Primary health care is committed to addressing dominant health problems at a society level, promoting individual and community self-reliance and participation, ensuring suitable health education is delivered and is connected to all other sectors in relation to community development [5]. Examples would be vaccinations or hand-sanitation in a viral pandemic. Primary health care focusses on the broader community’s health as a whole, ensuring social and economic development that is affordable and logistically attainable to all in the community in need and involves interdisciplinary collaboration. Primary care, on the other hand, focusses on sustaining individual health and maintaining relationships over time. Midwives, although not generally diagnosing and treating illness, are seen as primary carers as they are often the entry point into the maternity health system. Their scope of practice closely aligns with primary health care in providing antenatal, labour and birth and postnatal care that is woman-centred, geographically accessible, holistic and supports the woman’s full participation in taking ownership of her health and wellbeing [1]. Midwives work as part of a team, often referring to secondary and tertiary health services. Many of these values and principles are reflected in the International Confederation of Midwives’ Codes of Ethics [6] and the Nursing and Midwifery Board of Australia’s Code of Conduct for Midwives [7]. These documents also emphasise the point that maternal health is not just about the access to pregnancy, birth and newborn care, but is a greater public health issue. Important in this greater issue is the integration of referral pathways. This is usually for a particular purpose and for care that is outside the midwife’s expertise or scope of practice [7]. Eddy [3] mentions that midwives are also mindful of power and service access inequality and are often involved in political activism to ensure that women receive the care that they need and are entitled to. This involves the human right to engage with services that incorporate ‘body, mind, spirit, land, environment, culture, custom and the social determinants of health’ [3]. The social determinants of health that may affect midwifery healthcare include and are not limited to, genetics, healthy child development, social support networks, education, social and physical environments, health practices and services and culture. [8]. Health is a multi-faceted state of being that includes biological, social and ecological factors within the societal environment [8]. Midwives offer care with the belief that most women are healthy, and childbearing is a normal physiological process. Midwives are looked at as ‘guardians of the normal’ [9] and are not illness focussed. Healthy outcomes for women and children are expected and these results are being reflected within primary maternity care settings. Sandall’s [10] Cochrane review suggests that midwife-led continuity of care increases a women’s likelihood of, being more satisfied with her birth, having fewer interventions and analgesia and being with a midwife she knows for the process. Babies are also less likely to be born early and are at a lower risk of mortality [10]. A more recent Australian study evaluating a caseload midwifery program revealed similar favourable findings [11]. This further supports how primary health care provided by midwives contributes to healthy outcomes for women and their babies, maximising the gains that can be achieved during maternity care [3]. Healthy outcomes also rely on the aforementioned collaborative and supportive infrastructure being in place to assist midwives to provide comprehensive primary health care to cover any of these facets outside of their scope [3]. In summary, the difference between primary care and primary health care is one of scope. Primary care is concerned with meeting individual clients’ needs, while primary health care considers outcomes for the entire community.Working as primary carers, midwives also perform a broader function in the primary health care system by supporting and educating the woman and families in their care, and advocating for holistic equality to access basic health services leading to better health outcomes for society. References 1. Nursing and Midwifery Board of Australia, Midwife standards for practice. 2018. 2. Muldoon, L.K., W.E. Hogg, and M. Levitt, Primary care (PC) and primary health care (PHC). What is the difference? Canadian Journal Of Public Health = Revue Canadienne De Sante Publique, 2006. 97(5): p. 409-411. 3. Eddy, A., Midwifery as primary healthcare, in Midwifery Preparation for Practice, S. Pairman, et al., Editors. 2019. p. 79-88. 4. The Australian Government Department of Health. Primary care. 2020 [cited 2020 April 05, 2020]; Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/primarycare. 5. World Health Organisation. Declaration of Alma-Ata. 1978 [cited 2020 6/8/2020]; Declaration of Alma-Ata]. Available from: https://www.who.int/publications/almaata_declaration_en.pdf. 6. International Confederation of Midwives. International Code of Ethics for Midwives. 2008 2014. 7. Nursing and Midwifery Board of Australia, Code of conduct for midwives. 2018, Nursing and Midwifery Board of Australia.: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx. 8. McMurray, A. and J. Clendon, Community Health and Wellness - E-Book : Primary Health Care in Practice. 2014, Chatswood, AUSTRALIA: Elsevier Health Sciences. 9. Leap, N., Promoting physiological birth, in Midwifery Preparation for Practice, S. Pairman, et al., Editors. 2019. p. 347-361. 10. Sandall, J., Midwife-led continuity models versus other models of care for childbearing women (Review) Midwife-led continuity models versus other models of care for childbearing women (Review). Cochrane database of systematic reviews (Online), 2013: p. Art. No.: CD004667. 11. Gidaszewski, B., et al., Comparison of the effect of caseload midwifery program and standard midwifery-led care on primiparous birth outcomes: A retrospective cohort matching study. Midwifery, 2019. 69: p. 10-16. mark 75/1008/14/2020 0 Comments Community Engagement‘Birth for Humankind’ fosters strong community engagement by working with women and babies who present with complex needs. By increasing their confidence and knowledge and supporting them to overcome language and cultural barriers in the maternal health system, Birth for Humankind improves the health and wellbeing outcomes for these groups [1]. The word ‘community’ within the definition of ‘community engagement’ is defined as a group brought together by either geographical location, special interest, shared circumstances or a common vision [2-4]. Birth for Humankind was established to work with the Melbourne community of women at risk during their pregnancy, birth and post-partum period. This community includes women who are
When defining ‘engagement’ many words will present including collaboration, participation, connection and communication, but all involve some form of action or process to build relationship with the implication of benefitting the community [2-5]. Birth for Humankind does this by matching pregnant women with specifically trained doulas, providing education and informational support, ensuring language barriers are overcome, and offering continuity of emotional and physical care [6]. To further engage with this community, Birth for Humankind also provides education and information to the maternal health and allied service providers who support these women. This helps raise awareness of the barriers to respectful and appropriate maternity care faced by these women, and the impact this has on their health and wellbeing outcomes [1]. Birth for Humankind is a powerful example of community engagement, engaging with the community of birthing women in Melbourne who are experiencing additional challenges. This community engagement enables respectful, appropriate maternity care, for women to have the best birth possible and to improve the maternal and newborn health outcomes. References 1. Birth for Humankind Annual Report FY18-19. 2019: Birth for Humankind. 2. Community engagement - A key strategy for improving outcomes for Australian families. 2016 [cited 2020 07/03/2020]; CFCA Paper No. 39 – April 2016:[Available from: https://aifs.gov.au/cfca/publications/community-engagement/what-community-engagement. 3. van Delden, J.J.M. and R. van der Graaf, Revised CIOMS International Ethical Guidelines for Health-Related Research Involving Humans. JAMA, 2017. 317(2): p. 25-27. 4. Bowen, F., A. Newenham-Kahindi, and I. Herremans, When Suits Meet Roots: The Antecedents and Consequences of Community Engagement Strategy. Journal of Business Ethics, 2010. 95(2): p. 297-318. 5. Emergency risk communication training - Module B5: Community Engagement. [cited 2020 09/03/2020]; Emergency risk communication training - Mudule B5: Community Engagement]. Available from: https://www.who.int/risk-communication/training/module-b/en/index4.html. 6. O’Rourke, K.M., et al., An Australian doula program for socially disadvantaged women: Developing realist evaluation theories. Elsevier, 2019. Mark 67/1008/14/2020 0 Comments Opinion-Editorial - inductionPhotography: https://billbaren.com/pick-a-date-ep-18/ 43% of first time birthing women are being prescribed medication to induce the natural process of labour [1]. This number has increased by12% over ten years even though the World Health Organisation (WHO) recommends reducing unnecessary birth intervention [2]. Australian families are open and trusting of their care, yet they are not offered the full breadth of information around deciding on their baby’s birthdate. Their human dignity is being violated as this does not give women informed agency to participate in the decisions that affect their body and babies. The ‘Dignity of the human person’ is more than just being ranked evenly and focussed on the well-being of all. It is about having the rights to more than just the necessities in life, more than just a healthy mum and healthy baby. It’s the right to have our self-worth respected and to participate autonomously in the natural processes of our body without being controlled by an organisation’s policies and procedures [3]. The policies, procedures and recommendations within the medical setting are being guided by fear and litigation. The advice given misses relevant information about potential risks and negative outcomes for mother and baby. A risk that is often not discussed is that one drug intervention can lead to another. Inductions can be seen as the ‘gateway drug’ leading to pain and other medications that potentially result in a caesarean section. Caesarean rates are currently at 29.3% [1] when the WHO globally recommends a rate of between 10-15% [4]. Birthing women who had an induced labour had increased rates of haemorrhage (severe bleeding), longer hospital stays, more hospital re-admissions, caesarean section, hysterectomy, trauma and sometimes even death [5] [6]. Induction results in more stress and respiratory illness in the newborn. This leads to more separation from their mother, interrupted bonding, and less breastfeeding leading to many more illnesses [6]. These outcomes then hinder the realisation of the common good. ‘The Common Good’ can be defined as an extension of human dignity but for the greater community. Focus is applied to a structure that assists in the flourishment and fulfilment of the whole group [7]. The common good is a collaboration of the community to implement a framework to aspire to live together in a common space in a manner that supports all. This can also expand to injustice on a local and global level. The impacts of unnecessary induction affects us all in an economic [8], ecological and emotional [9, 10] way and do not reflect a framework of collaboration [7]. I was one of those women prescribed the medication to push along my labour. Now more educated, I realise this was unnecessary and lead to further pain medication due to its increased, non-physiological effects. This ultimately led to an instrumental birth, cut perineum and me and my baby being compromised during birth and for an extended time postnatally. As a birth worker I have witnessed many women being induced without true medical need or informed consent. I have also supported families informing themselves at each point of their journey, often making an informed refusal of medication offered. No matter the outcome, families informing themselves tend to come through that process far more emotionally and psychologically intact with the general feeling that if they did have an induction it was medically necessary [11]. When working with families and addressing the dignity of the human person and the realisation of the common good in my future practice as a midwife, I will address the WHO recommendations to reduce unnecessary intervention by working to provide continuity of care, not intervening too early and avoiding overuse of continuous electronic monitoring (CTG) [2]. I will also be mindful of ensuring that the advice of an induction is given and accepted with full informed consent [11]. With the statistics and outcomes being reported over and over again, it is not evident the decision for induction is being made on true medical need as recommended by Guerra, Cecatti [5]. It is also not evident that the human dignity of the birthing woman or emerging baby is being fully respected and ultimately the realisation of the common good within our Australian community. It is up to the next wave of informed and compassionate maternity health professionals to advocate for these changes to ensure humanity is preserved at a global level. References 1. National Core Maternity Indicators 2017: Summary Report, A.I.o.H.a. Welfare, Editor. 2019, Australian Institute of Health and Welfare: Canberra. 2. WHO recommendations: intrapartum care for a positive childbirth experience. 2018, World Health Organisation: Geneva. 3. Catholic Social Teaching. 2019 [cited 2019 16/12/2019]; Available from: https://www.socialjustice.catholic.org.au/social-teaching. 4. Betran, A., et al., WHO Statement on Caesarean Section Rates. BJOG: An International Journal of Obstetrics & Gynaecology, 2016. 123(5): p. 667-670. 5. Guerra, G.u.V.n., et al., Elective induction versus spontaneous labour in Latin America. Bulletin of the World Health Organization, 2011. 89(9): p. 657-665. 6. Mack, K., AWHONN recommends reducing overuse of labor induction. 2014, Eurekalert: https://www.eurekalert.org. 7. Velasquez, M., et al. The Common Good. 2014 [cited 2019 17/12/2019]; Available from: https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/the-common-good/. 8. Callander, E.J. and H. Fox, What are the costs associated with child and maternal healthcare within Australia? A study protocol for the use of data linkage to identify health service use, and health system and patient costs. BMJ Open, 2018. 9. Delicate, A., et al., The impact of childbirth-related post-traumatic stress on a couple's relationship: a systematic review and meta-synthesis. Journal of Reproductive & Infant Psychology, 2018. 38(1): p. 102-115. 10. da Silva Lima, B.C., et al., Feelings amongst high-risk pregnant women during induction of labor: a descriptive study. Online Brazilian Journal of Nursing, 2016. 15(2): p. 254-263. 11. Jenkinson, B., S. Kruske, and S. Kildea, The experiences of women, midwives and obstetricians when women decline recommended maternity care: A feminist thematic analysis. Midwifery, 2017. 52: p. 1-10. MARKED: HDIn this essay, I reflect on my interpersonal communication and motivational interviewing skills (Rollnick, Miller, & Butler, 2012). I do this by evaluating my case scenario role play, and the feedback forms from other students. In the role play, I interviewed Sally after she visited her doctor who had advised against surgery for weight loss. I played the clinic nurse taking her blood pressure after her appointment. I will evaluate, interpret and reference my observations of where I thought I did well and how I think I could have improved the interaction. In relation to Rollnick et al.’s (2012) Spirit of Motivational Interviewing, I feel I did well to express their ideas of compassion and acceptance by using body language, nodding, responses of ‘ah-hah’ and explicit paraphrasing and reflecting of what Sally said. For example when I reflected back to Sally the positive changes she wanted to make towards her weight loss. I worked well in partnership with Sally, assisting her to refine her goals, finding out what she had tried, and working out together how to achieve these goals. I did this by listening and acknowledging her realisation of the benefit of exercise in accomplishing her objective. I think I could have worked more on evoking Sally’s own ideas for change by eliciting ‘that which is already there’ (Miller & Rollnick, 2009). In suggesting a nutritionist, I attempted to fix the situation rather than motivate Sally to find that path (Barkway, 2013, pp. 172-173). I also expressed my own values around the taste of pre-packaged meals, but I feel this helped build rapport and understanding and guided us to find a more palatable solution. I made good use of open-ended questions to elicit unbiased responses and to encourage free and open change speech (Ostlund, Wadensten, Haggstrom, Lindqvist, & Kristofferzon, 2016). I asked Sally if she had thought about other exercises to incorporate into her routine. On a few occasions I recognised, reflected and affirmed change talk by letting her know Ithought her ideas were great initial steps to take. I acknowledge that my repetitive ‘hearing you’ when doing this may be interpreted as rote and I need to work on better phrasing. In our conversation I found there was a strong presence and elicitation of change talk with statements like ‘yeah it’s easy’ from Sally and ‘Is there any other benefits you can see...?’ from me. I think I did well to maintain and sharpen this focus to stay on topic with directional questions helping her think about specific exercise options that could support her knee situation. I was fortunate that Sally already expressed a readiness to change. I would place her at the ‘Contemplation’ stage of Prochaska, DiClemente, and Norcross’s (1997) Transtheoretical Model of Change model and I identify I could have done better supporting her to set an agenda and develop a plan for further preparation. Overall, I enjoyed completing this exercise and felt I did well listening, paraphrasing and reflecting. This involved constantly assessing readiness to change and affirming, recognising and reinforcing change talk. I did this by expressing empathy through kindness and reassurance whilst also maintaining focus. I however could have improved my interaction by evoking more, offering solutions less and reducing repetitive paraphrasing. References
Barkway, P. (2013). Psychology for health professionals (2nd ed.). Sydney, N.S.W.: Churchill Livingstone/Elsevier. Miller, W. R., & Rollnick, S. (2009). Ten Things that Motivational Interviewing Is Not. Behavioural and Cognitive Psychotherapy, 37, 129-140. doi:10.1017/S1352465809005128 Ostlund, A.-S., Wadensten, B., Haggstrom, E., Lindqvist, H., & Kristofferzon, M.-L. (2016). Primary care nurses’ communication and its influence on patient talk during motivational interviewing. Journal of Advanced Nursing 72(11), 2844-2856. doi:10.1111/jan.13052 Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1997). In search of how people change: applications to addictive behaviors. In G. A. Marlatt & G. R. VandenBos (Eds.), Addictive Behaviors: Readings on Etiology, Prevention, and Treatment (pp. 671-696). Washington: American Psychological Association. Rollnick, S., Miller, W. R., & Butler, C. C. (2012). Motivational interviewing: Helping people change ( 3rd ed.). New York, NY: Guildford Press. The Transtheoretical Model of Change (Prochaska, DiClemente, & Norcross, 1997) and Motivational Interviewing (Rollnick, Miller, & Butler, 2012) are techniques used to understand and implement behaviour change in a therapeutic setting. It is important that we as health care practitioners provide support and assistance to clients who are overweight or obese to address the underlying cause of many chronic diseases. (Kushner & Ryan, 2014) Harry is a 58-year-old chef whose persistent high weight is impacting his health. Overweight and obesity account for 67% (Overweight and obesity: an interactive insight, 2019) of Australia’s population and is one of the country’s nine National Health Priorities. Specifically, obesity is more prevalent in foodservice employees (Pizam, 2013). In this essay I will firstly define the stages of the proposed models, where this case fits within them, and then define how best to utilise Motivational Interviewing in changing Harry’s situation towards better health habits in the four days he is within my care. The Transtheoretical Model of change (Prochaska, DiClemente, & Norcross, 1997), from herein referred to as ‘TTM’, proposes a cognitively based therapy to support progress to more therapeutic actions that are ongoing. It is defined by five progressive stages with an extra stage for relapse and termination option. Movement does not need to progress forward, but the aim is to do so. The stage of ‘pre-contemplation’ is defined as the person not considering, showing interest or recognising the need to change. They may not even know or think it is possible or necessary. In Harry’s situation, I believe this is where we might place him. He states “I’ve been overweight for years and that’s just how I am.” This gives me the impression of denial and a person-centred mentality to his current weight situation. At this stage I would build a rapport with Harry and ask some open-ended questions that may lead to awareness and thought about the benefits of some lifestyle changes. I will address this more in-depth later in relation to Motivational Interviewing. The next stage in this model is ‘contemplation’ where the person is aware and may have intention or is thinking about modifying their behaviour. Often this is brought about by an incident and although I feel Harry is not quite at this point, I feel he is close. He is aware his doctor has concerns and potentially Harry’s surgery tomorrow will have the effect of triggering more thought and consideration, but perhaps still with some ambivalence. Positive feedback is of great benefit at this time. Should Harry progress through this ambivalence, he may then start thinking about actual change. That would then move Harry into the model’s ‘preparation’ stage defined as an intention or commitment to change. Harry may start making plans to try and integrate a healthier lifestyle into his everyday life. He may book to see a dietitian or start walking to work. Encouragement and help adapting these modifications comfortably into his timetable would support this stage that may take up to 30 days before it is beneficial, and action occurs. The stage of ‘action’ is when these new planned changes are adopted and are showing therapeutic benefit. This initiation will still need effort and determination and may last up to 3-6 months. Harry, at this point, might need his commitment strengthened and acknowledgment of the steps he has taken. If possible, Harry would be motivated to avoid people or places that may negatively affect his progress. The goal stage of TTM is ‘maintenance’ and occurs when there is ongoing, sustained, integrated practice of the new health behaviour. For some people this stage may be the completion of the TTM model as the outcome has now been reached (termination). In Harry’s case this would be an ongoing exercise and support may be to encourage him to share his experiences and connect with others in a peer support environment. If Harry was in my care at this time I may offer him some research like the movement of chef’s making menu changes in their workplace (Obbagy, Condrasky, Roe, Sharp, & Rolls, 2011). The effort now is to protect against relapse. Relapse can happen at any stage. Barkway (2013) states ‘When relapse occurs the person is encouraged to view this as part of the cycle of change, not failure – a challenge not a catastrophe.’ The relapse can revert the person to any of the aforementioned stages and should be readdressed with the support applicable to that stage. For Harry we may also have a relapse plan built into each stage that may account for holidays, busy times at the restaurant or even changing his job. Given Harry’s age, it may also be applicable to think about Harry’s retirement and how that may impact his lifestyle. As previously mentioned, I would place Harry at the ‘pre-contemplation’ stage due to his denial of there being an issue. I will now address how I can utilise Motivational Interviewing to support him and help him move in the direction of ‘maintenance’. Motivational Interviewing (Rollnick, Miller, & Butler, 2012), from herein referred to as ‘MI’, like TTM, encourages the practitioner to support and guide the client themselves to realise the need for change. This requires the client to recognise their own ambivalence and their readiness to grow with interaction with their practitioner. The interaction is generally quiet, with the practitioner encouraging resolution to the ambivalence in partnership with the client. This method of intervention has been shown to influence physical behaviour in a positive way. (Rodriguez-Cristobal, et al., 2017) The mind- and heart-set of MI is called the ‘Spirit of Motivational Interviewing’ and is made up of some key elements that seek to avoid trying to manipulate clients into our own agenda. (Rollnick, Miller, & Butler, 2012). These elements consist of partnership, acceptance, compassion and evocation. With these elements in mind, I would address supporting Harry by considering the four stages of MI. When first meeting Harry I would seek to engage his trust and build a relationship. Introducing myself and my capacity within the surgical ward with my intention to be caring for him for the next four days. Some open-ended questions of engagement may be around how he is feeling, what keeps him busy out of hospital, family and social connections, and even just chat about the weather. I may also try to find some similarities or understanding in my own life to reflect back without getting too personal. Acceptance and compassion here may be prevalent and listening for any uneasiness leading up to his hip surgery tomorrow. I might also be listening during the day for some opportunity to ask him if the reasons for his impending surgery have had much impact on his life and if perhaps there was anything he might change to lesson that impact. This may open an opportunity for me listen for change talk and to offer myself to support him with some ideas to perhaps think about until tomorrow. When caring for Harry the following day, post his surgery, we may then look at focusing in on some more specific issues. Harry may have now transitioned from the TTM ‘pre- contemplation’ to ‘contemplation’ stage and is more open or showing desire to change. Responding to Harry with a question like ‘I’m hearing that you feel your weight is normal for someone working in your profession around food all day. Can you tell me a little bit about this?’ The answer may then give us a direction or focus to develop discrepancy and, pending readiness, look at ways to change. I might also hand him some information about the increased risks of other diseases associated with his condition to give him an opportunity to inform himself during his recovery time at the hospital. With this direction and focus in mind, we might then try to discover Harry’s own motivation to evoke the realised necessary changes. I would help him gather his own ideas and feelings about how he might accomplish these. Asking him questions about what he thought about the information I had given him previously, how he has overcome things in the past, and for the things that have not worked, does he know how they could be modified. This would be a collaborative discussion with me motivating him to find positive behaviours and feeding back positive affirmations This focus and goal finding exploration may take a few days of conversation and consultation that I would address with Harry using open ended questions, positive affirmations of progress and decisions, reflection and summary of what I have heard and understood of his communication. Before my four days come to an end, I would reflect back to Harry any plans that he had spoken about and if they were specific, measurable, achievable, relevant and timed, and would again offer affirmations and motivations to continue on the path he is on into the future. In summary, moving Harry from an external ‘locus of control’ style (Rotter, 1966), into a more ‘internal’ state of self-efficacy where he can feel able to modify his behaviour rather than him just feeling ‘that’s just how I am... I am around food all day long’ is a positive goal to have within the four days of my care. This can be accomplished very effectively utilising the Transtheoretical Model of change and Motivational Interviewing (DiLillo & West, 2011). Addressed in partnership and with acceptance, compassion and evocation, Harry can be well supported on his way to maintenance. Bibliography
Barkway, P. (2013). Psychology for health professionals (2nd ed.). Sydney, N.S.W.: Churchill Livingstone/ Elsevier. DiClemente, C. C., Shumann, K., Greene, P. A., & Earley, M. D. (2011). A transtheoretical model perspective on change: process-focussed intervention in mental health- substance use. In D. B. Cooper, Intervention in Mental Health-Substance Use (pp. 69- 87). London: Radcliffe Publishing. DiLillo, V., & West, D. S. (2011). Motivational Interviewing for Weight Loss. Psychiatric Clinics of North America, 861-869. https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an-interactive- insight, A. I. (2019). Overweight and obesity: an interactive insight. Retrieved from Australian Institute of Health and Welfare: https://www.aihw.gov.au/reports/overweight-obesity/overweight-and-obesity-an- interactive-insight Kushner, R. F., & Ryan, D. H. (2014, September 3). Assessment and Lifestyle Management of Patients With Obesity Clinical Recommendations From Systematic Reviews. JAMA, 312(9), 943-952. Obbagy, J. E., Condrasky, M. D., Roe, L. S., Sharp, J. L., & Rolls, B. J. (2011, February). Chefs’ Opinions about Reducing the Calorie Content of Menu Items in Restaurants. Obesity Journal, 19(2), pp. 332-337. Pizam, A. (2013, March). The prevalence of obesity among foodservice employees. International Journal of Hospitality Management, 32, 1. Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1997). In search of how people change: applications to addictive behaviors. In A. G. Marlatt, & G. R. VanderBos, Addictive behaviors: Readings on etiology, prevention, and treatment (pp. 671-696). Washington, D.C.: American Psychological Association. Riekert, K. A., Borrelli, B., Bilderback, A., & Rand, C. S. (2011, January). The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Education and Counseling, 82(1), 117-122. Rodriguez-Cristobal, J. J., Alonso-Villaverde, C., Panisello, J. M., Travé-Mercade, P., Rodriguez-Cortés, F., Marsal, J. R., & Peña, E. (2017, June 20). Effectiveness of a motivational intervention on overweight/obese patients in the primary healthcare: a cluster randomized trial. BMC Family Practice. Rollnick, S., Miller, W. R., & Butler, C. C. (2012). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guildford Press. Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs 80. VanBuskirk, K. A., & Wetherell, J. L. (2013, August 11). Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med, 768- 780. 8/14/2020 0 Comments Breast Cancer biology case studyVodcast Bibliography
Slide 1 Image – Personal Photo (Askham, 2015) Slide 3 Image - https://en.wikipedia.org/wiki/Malignancy#/media/File:Types_of_tumor_cells.jpg (Manu5, 2018) Benign / malignant – Human Anatomy & Physiology, Elaine N. Marieb & Kayja Joehn (8th Edition) (Marieg & Joehn, 2010) Slide 5 Image - https://www.verywellhealth.com/diagnosis-and-testing-for-her2-positive-breast-cancer-4151804 (Gilmartin , 2019) Reference - HER2-positive breast cancer: What is it? MYO Clinic Website https://www.mayoclinic.org/breast-cancer/expert-answers/faq-20058066 (Moynihan, 2018) Slide 6 Images – personal (Askham, 2015) Pain (Bullock & Majella, 2019, p. 84) Slide 7 Image - https://www.health24.com/Medical/Anaemia/News/Anaemia-20120721 (iStock, 2019) Erythropoietin & myelosuppression (Bullock & Majella, 2019, p. 84) Slide 8 Image – personal (Askham, 2015) Slide 9 Image – personal (Askham, 2015) Chemotherapy defn. (Bullock & Majella, 2019, p. 90) Statistics - (Public Health England, n.d.) ADC - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6359697/ (Nejadmoghaddam, et al., 2019) Annotated BibliographyAskham, J. L. (2015). Personal Photos. These photo images are to add real life visuals of my client's experience. Bullock, S., & Majella, H. (2019). Principles of Pathophysiology (Vol. 2nd Edition). Melbourne, VIC: Pearson Australia. References from this subject textbook aided in defining and explaining pain and anemia. Gilmartin , B. (2019, September 24). HER2 Testing in Breast Cancer. Retrieved from Verywell Health: https://www.verywellhealth.com/diagnosis-and-testing-for-her2-positive-breast-cancer-4151804 Easy to understand image of the normal and HER2 positive cancer cell with increased HER2 receptors. iStock. (2019, March 01). Anaemia. Retrieved from Health24: https://www.health24.com/Medical/Anaemia/News/Anaemia-20120721 Attractive red blood cell image. Manu5. (2018, February 15). Malignancy. Retrieved from Wikipedia: https://en.wikipedia.org/wiki/Malignancy#/media/File:Types_of_tumor_cells.jpg Easy and clear to understand image of the difference between a malignant and benign neoplastic growth Marieg, E. N., & Joehn, K. (2010). Human Anatomy & Physiology (Vol. 8th). San Francisco: Pearson Benjamin Cummings. This textbook contained little about neoplastic growth but explained simply malignant and benign neoplastic growth Moynihan, T. J. (2018, November 02). HER2-positive breast cancer: What is it? Retrieved from Mayo Clinic: https://www.mayoclinic.org/breast-cancer/expert-answers/faq-20058066 An article in response to the question 'A friend of mine has HER2-positive breast cancer. Can you tell me what this means?' that explains the pathophysiology of the HER2+ diagnosis.Nejadmoghaddam, M.-R., Minai-Tehrani, A., Ghahremanzadeh, R., Mahmoudi, M., Dinarvand, R., & Zarnani, A.-H. (2019). Antibody-Drug Conjugates: Possibilities and Challenges. Avicenna Journal of Medical Biotechnology, 3-23. A complex article addressing Antibody-Drug Conjugates that I only used to get a better understanding of the treatment. Public Health England. (n.d.). Predict Breast Cancer. Retrieved October 2019, from Predict Tool: https://breast.predict.nhs.uk/tool A prediction tool I used to determine the prognosis specific to Charlotte’s factors in relation to her cancer diagnosis. 4/15/2020 0 Comments MUSIC FESTIVAL ATTENDEES’ ILLICIT DRUG USE, KNOWLEDGE AND PRACTICES REGARDING DRUG CONTENT AND PURITY: A CROSS SECTIONAL SURVEYDay, N., Criss J., Griffiths, B., Gujral, S.K., John-Leader, F., Johnson, J., & Pit, S. (2018). Music festival attendees’ illicit drug use, knowledge and practices regarding drug content and purity: A cross-sectional survey. Harm Reduction Journal, 15(1), 1-8. doi: 10.1186/s12954- 017-0205-7 From herein referred to as the ‘study’ Illicit drug use is high in festival attendees and drug testing has been shown to reduce harm in other countries. In this essay I will focus on critically appraising the strengths and weakness of the study utilising Greenhalgh’s five question process (Greenhalgh, Bidewell, Crisp, Lambros, & Warland, 2017, pp. 27-28), CASP (Critical skills appraisal program, 2019), and the Joanna Briggs Institute Critical Appraisal tools (Joanna Briggs Institute, 2019). I will review authorship, critically appraise the aims, design, methods, results and limitations of the research and describe factors affecting the implementation of the findings into the case scenario provided. All authors have relevant expertise, having affiliations with academic or health-based government institutions. The collaboration of authors adds to the quality of the study as it reduces the risk of lack of expertise. Jennifer Johnston has also published previous research about pill testing (Johnston, et al., 2006) and brings this knowledge to this study. A conflict of interest is defined by Oxford (English Oxford Living Dictionaries, 2019) specifically in relation to research, as a situation in which a author is in a position to gain personal benefit from decisions made or actions taken from the results of the paper. The authors declare there are no competing interests although concern could be raised as to whether reflexivity (Greenhalgh,Bidewell, Crisp, Lambros, & Warland, 2017, p. 39) was used to ensure their own ideas on the drug testing debate did not influence the data analysis, in particular Franklin John-Leader’s affiliation with a harm reduction and health promotion program. There is a sense that the study is building proof supporting the use of drug testing in response to the Australian Senate calling for more evidence to substantiate its efficacy. The abstract and title clearly describe the four study aims - to investigate the proportion of illicit drug use in young people; the patterns of illicit drug use in young people; the young people’s attitudes towards drug checking at festivals; and the potential impact of drug checking on intended use behaviour. The rationale for the study was highlighted in relation to the reduction of harm from use of compromised drugs. Australia has a high rate of illicit drug use in those attending music festivals. Local research would add value by building on previous research and identifying whether overseas findings were applicable here. As mentioned in the study, utilisation of these services along with information raising awareness of harmful drugs, has resulted in a decline of these products on the market in many European countries, but Australia’s lack of evidence has created a gap that this study addresses. According to National Collaborating Centre for Methods and Tools (Robinson, Saldanha, & Mckoy, 2011) a research gap is where there is missing or insufficient information that limits forming conclusions within that area or topic. The authors undertook a cross-sectional survey for their primary study working with a representative sample of a larger group at a single point in time. (Greenhalgh, Bidewell, Crisp, Lambros, & Warland, 2017). The survey was predominantly quantitative with one supplementary, open-ended qualitative question for the drug users in the group. Greenhalgh (2017, p.30) defines results from descriptive or inferential studies that are given in numbers and analysed statistically asquantitative. This method gives strength and reliability through repeating number results. The open- ended, embedded question enabled qualitative data, which supplemented elements of the research question. (Greenhalgh, Bidewell, Crisp, Lambros, & Warland, 2017, p. 100) The design was appropriate, pilot tested and justified for the research aims of the study. The authors accessed their sample through an established sexual health promotion stall at a two-day festival. The festival venue was appropriate but surveying only the patrons of the stall may diminish the randomness strength of the pool sample to only those interested in sexual health. 642 visibly sober participants were recruited during daylight hours to reduce the potential of intoxication. I am sceptical that this is an appropriate recruitment method as it may be biased towards non-drug users who are more likely to be around during the day and potentially contain intoxicated participants who are visibly sober. The strength of the data collected was enhanced by using a valid, ethically approved, piloted survey tool and evaluated using Likert scales that are designed to establish participants’ feelings or positions (Grove & Gray, 2019), thematic analysis of the free text data to draw out broad themes to allocate for coding (Greenhalgh, Bidewell, Crisp, Lambros, & Warland, 2017), and the statistical significance was calculated using p-values. The aims were answered by the study but the first, second, and fourth aims were answered specifically for festival attendees as opposed to young people in general. The authors have determined some limitations to their study which include the small size and disproportionate number of female participants. Other limitations may be the single instance of data collection, addressing a particular stall demographic, questionable proportion of drug users and possible intoxication. A limitation in the results analysis may be that it is more relevant to assess the attitudes towards drug testing specifically for the users and not just the whole study sample. Emily’s mother is worried that drug testing at the festival her daughter will be attending will encourage her daughter to use illicit drugs. The clinical question from this case may be ‘Does the presence of illicit drug testing increase the usage of illicit drugs taking in music festival attendees?’ The appraised study (Day, et al., 2018) does not directly answer this question but could inform future research into its effects on usage. The potential organisational barriers - factors preventing successful implementation of evidence (Hoffmann, Bennett, & Del Mar, 2017) in the uptake of the finding into practice may be lack of government support which would equate to lack of resources such as money, time and skill building. There is also a cultural barrier that such support would be perceived as advocating drug usage. This is the concern of Emily’s mother on an individual level. Other individual barriers may be lack of knowledge of the testing, the festival goers’ time to have the test and the lack of confidence in the research or testing process. The authors’ recommendations to contribute this information to the drug testing debate, increased understanding in the potential harm reduction and sharing current knowledge with parents and young people may promote research in this area to give Emily’s mother the answer she is after. Other enabling factors that might increase the likelihood of its success (Hoffmann, Bennett, & Del Mar, 2017) on an organisational level would be also for increased education about the potential harm reduction, more support for further research and open discussion and sharing on a government and community level. In this article, knowledge and practice in regard to drug content and purity has gone a long way. The study was conducted by a good number of knowledgeable authors, contained clear aims and justifications, an appropriate design, and ethical and piloted methods that were strengths that created the desired findings. Some limitations were mentioned around potential conflict of interest and bias, but the biggest problem was around population sampling. I wonder if perhaps assessing the attitudes towards drug testing of the same people in varied situations may offer different choices. For example, if participants were intoxicated or asked the questions away from the festival, would they still provide the same answers? I would classify this study as high quality, but surmise it is not in a situation to fully apply into clinical practice. REFERENCES
Critical skills appraisal program. (2019, May 20). Retrieved from Critical skills appraisal program: http://www.casp-uk.net/ Day, N., Criss, J., Griffiths, B., Gujral, S. K., John-Leader, F., Johnston, J., & Pit, S. (2018). Music festival attendees’ illicit drug use, knowledge and practices regarding drug content and purity: A cross-sectional survey. Harm Reduction Journal, 15(1). English Oxford Living Dictionaries. (2019, 05 20). Retrieved from English Oxford Living Dictionaries: https://en.oxforddictionaries.com/definition/conflict_of_interest Greenhalgh, T. M., Bidewell, J., Crisp, E., Lambros, A., & Warland, J. (2017). Understanding Research Methods for evidence-based practice in health. Wiley. Grove, S. K., & Gray, J. R. (2019). Understanding Nursing Research: building on Evidence-based Practice. Missouri, USA: Elsevier. Hoffmann, T., Bennett, S., & Del Mar, C. (2017). Evidence-Based Practice Across Health Professions, Third Edition. Chatswood: Elsevier Australia. Joanna Briggs Institute. (2019, May 20). Retrieved from Joanna Briggs Institute: https://www.joannabriggs.org/critical_appraisal_tools Johnston, J., Barratt, M. J., Fry, C. L., Kinner, S., Stoové, M., Degenhardt, L., . . . Bruno, R. (2006, December). A survey of regular ecstasy users’ knowledge and practices around determining pill content and purity: Implications for policy and practice. International Journal of Drug Policy, 17(6), 464-472. Robinson, K. A., Saldanha, I. J., & Mckoy, N. A. (2011, May 20). Frameworks for determining research gaps during systematic reviews. Methods Future Research Needs Report No. 2. (A. f. Quality, Producer, & Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. HHSA 290-2007-10061-I) Retrieved May 2018, from National Collaborating Centre for Methods and Tools: https://www.nccmt.ca/knowledge- repositories/search/118 11/14/2019 0 Comments Reliable un~reliabilityShould I become less reliable to cope better with others reliable unreliability?
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