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1.  Local guidelines for the transfer of women from midwifery unit to obstetric unit during labour in England: a systematic appraisal of their quality 
A proportion of women planning to give birth in a midwifery unit will experience complications during labour that necessitate transfer to an obstetric unit. Local guidelines for the transfer of women in labour have the potential to impact on quality of care and the safety of the transfer process.
To systematically appraise the quality of local NHS guidelines on the transfer of women from midwifery unit to obstetric unit during labour.
Guidelines were requested from all 52 NHS hospital trusts in England with midwifery units. The Appraisal of Guidelines for Research and Evaluation Instrument was used to evaluate the quality of the guidelines received.
Relevant guidelines were received from 34 (65%) trusts. No guidelines scored on the ‘editorial independence’ domain. The mean score on ‘scope and purpose’ (56.2%), concerned with the aims, clinical questions and target patient population of the guideline, was higher than for other domains: ‘clarity and presentation’ (language and format) 45.3%, ‘stakeholder involvement’ (representation of users’ views) 15.3%, ‘rigour of development’ (process used to develop guideline) 15.0%, ‘applicability’ (organisational, behavioural and cost implications of applying guideline) 7.1%. Only three guidelines were recommended for use in clinical practice.
We believe this to be the first systematic appraisal of the quality of local NHS guidelines. Overall these local guidelines were of poor quality. It is not clear whether the quality of these midwifery guidelines is typical of local guidelines in other clinical areas, but this study raises fundamental questions about the appropriate development of high-quality local clinical guidelines.
PMCID: PMC2929588  PMID: 20351156
2.  Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently 
Quality & safety in health care  2003;12(6):428-434.
Objective: To determine whether North American guidelines published subsequent to and in the same topic areas as those developed by the US Agency for Health Care Policy and Research (AHCPR) meet the same methodological criteria.
Study design: A guideline appraisal instrument containing 30 criteria was used to evaluate the methodological quality of the AHCPR guidelines, "updates" of the AHCPR guidelines authored by others, and guidelines that referenced or were adapted from the AHCPR guidelines. The frequency with which the criteria appeared in each guideline was compared and an analysis was performed to determine guidelines with two key features of the ACHPR guidelines—multidisciplinary guideline development panels and systematic reviews of the literature. Data were extracted from the guidelines by one investigator and then checked for accuracy by the other.
Results: Fifty two guidelines identified by broad based searches were evaluated. 50% of the criteria were present in every AHCPR guideline. The AHCPR guidelines scored 80% or more on 24 of the 30 criteria compared with 14 for the "updates" and 11 for those that referenced/adapted the AHCPR guidelines. All of the 17 AHCPR guidelines had both multidisciplinary development panels and systematic reviews of the literature compared with five from the other two categories (p<0.05).
Conclusions: North American guidelines developed subsequent to and in the same topic areas as the AHCPR guidelines are of substantially worse methodological quality and ignore key features important to guideline development. This finding contrasts with previously published conclusions that guideline methodological quality is improving over time.
PMCID: PMC1758044  PMID: 14645758
3.  Comparison of midwifery students’ satisfaction with direct observation of procedural skills and current methods in evaluation of procedural skills in Mashhad Nursing and Midwifery School 
The clinical evaluation, as one of the most important elements in medical education, must measure students’ competencies and abilities. The implementation of any assessment tool is basically dependent on the acceptance of students. This study tried to assess midwifery students’ satisfaction with Direct Observation of Procedural Skills (DOPS) and current clinical evaluation methods.
Materials and Methods:
This quasi-experimental study was conducted in the university hospitals affiliated to Mashhad University of Medical Sciences. The subjects comprised 67 undergraduate midwifery students selected by convenience sampling and allocated to control and intervention groups according to the training transposition. Current method was performed in the control group, and DOPS was conducted in the intervention group. The applied tools included DOPS rating scales, logbook, and satisfaction questionnaires with clinical evaluation methods. Validity and reliability of these tools were approved. At the end of training, students’ satisfaction with the evaluation methods was assessed by the mentioned tools. The data were analyzed by descriptive and analytical statistics.
Satisfaction mean scores of midwifery students with DOPS and current methods were 76.7 ± 12.9 and 62.6 ± 14.7 (out of 100), respectively. DOPS students’ satisfaction mean score was significantly higher than the score obtained in current method (P < 0.000). The most satisfactory domains in the current method were “consistence with learning objectives” (71.2 ± 14.9) and “objectiveness” in DOPS (87.9 ± 15.0). In contrast, the least satisfactory domains in the current method were “interested in applying the method” (57.8 ± 26.5) and “number of assessments for each skill” (58.8 ± 25.9) in DOPS method.
This study showed that DOPS method is associated with greater students’ satisfaction. Since the students’ satisfaction with the current method was also acceptable, we recommend combining this new clinical evaluation method with the current method, which covers its weaknesses, to promote the students’ satisfaction with clinical evaluation methods in a perfect manner.
PMCID: PMC3748577  PMID: 23983736
Clinical competence; clinical evaluation; direct observation of procedural skills; documentation; evaluation studies; Iran; logbook; personal satisfaction; students’ satisfaction
4.  A protocol for evaluating progressive levels of simulation fidelity in the development of technical skills, integrated performance and woman centred clinical assessment skills in undergraduate midwifery students 
BMC Medical Education  2013;13:72.
Simulation as a pedagogical approach has been used in health professional education to address the need to safely develop effective clinical skills prior to undertaking clinical practice. However, evidence for the use of simulation in midwifery is largely anecdotal, and research evaluating the effectiveness of different levels of simulation fidelity are lacking.
Woman centred care is a core premise of the midwifery profession and describes the behaviours of an individual midwife who demonstrates safe and effective care of the individual woman. Woman centred care occurs when the midwife modifies the care to ensure the needs of each individual woman are respected and addressed. However, a review of the literature demonstrates an absence of a valid and reliable tool to measure the development of woman centred care behaviours. This study aims to determine which level of fidelity in simulated learning experiences provides the most effective learning outcomes in the development of woman centred clinical assessment behaviors and skills in student midwives.
Three-arm, randomised, intervention trial.
In this research we plan to:
a) trial three levels of simulation fidelity - low, medium and progressive, on student midwives performing the procedure of vaginal examination;
b) measure clinical assessment skills using the Global Rating Scale (GRS) and Integrated Procedural Performance Instrument (IPPI); and
c) pilot the newly developed Woman Centred Care Scale (WCCS) to measure clinical behaviors related to Woman-Centredness.
This project aims to enhance knowledge in relation to the appropriate levels of fidelity in simulation that yield the best educational outcomes for the development of woman centred clinical assessment in student midwives. The outcomes of this project may contribute to improved woman centred clinical assessment for student midwives, and more broadly influence decision making regarding education resource allocation for maternity simulation.
PMCID: PMC3666945  PMID: 23706037
Clinical assessment; Education; Global rating scale; Integrated procedural performance instrument; Midwifery; Simulation; Simulation fidelity; Vaginal examination; Woman centred care
5.  Continuity of midwifery care and gestational weight gain in obese women: a randomised controlled trial 
BMC Public Health  2011;11:174.
The increased prevalence of obesity in pregnant women in Australia and other developed countries is a significant public health concern. Obese women are at increased risk of serious perinatal complications and guidelines recommend weight gain restriction and additional care. There is limited evidence to support the effectiveness of dietary and physical activity lifestyle interventions in preventing adverse perinatal outcomes and new strategies need to be evaluated. The primary aim of this project is to evaluate the effect of continuity of midwifery care on restricting gestational weight gain in obese women to the recommended range. The secondary aims of the study are to assess the impact of continuity of midwifery care on: women's experience of pregnancy care; women's satisfaction with care and a range of psychological factors.
A two arm randomised controlled trial (RCT) will be conducted with primigravid women recruited from maternity services in Victoria, Australia. Participants will be primigravid women, with a BMI≥30 who are less than 17 weeks gestation. Women allocated to the intervention arm will be cared for in a midwifery continuity of care model and receive an informational leaflet on managing weight gain in pregnancy. Women allocated to the control group will receive routine care in addition to the same informational leaflet. Weight gain during pregnancy, standards of care, medical and obstetric information will be extracted from medical records. Data collected at recruitment (self administered survey) and at 36 weeks by postal survey will include socio-demographic information and the use of validated scales to measure secondary outcomes.
Continuity of midwifery care models are well aligned with current Victorian, Australian and many international government policies on maternity care. Increasingly, midwifery continuity models of care are being introduced in low risk maternity care, and information on their application in high risk populations is required. There is an identified need to trial alternative antenatal interventions to reduce perinatal risk factors for women who are obese and the findings from this project may have application in other maternity services. In addition this study will inform a larger trial that will focus on birth and postnatal outcomes.
Trial Registration
Australian New Zealand Clinical Trials Registry ACTRN12610001078044.
PMCID: PMC3074543  PMID: 21426582
6.  Toward Evidence-Based Quality Improvement: Evidence (and its Limitations) of the Effectiveness of Guideline Dissemination and Implementation Strategies 1966–1998 
Journal of General Internal Medicine  2006;21(Suppl 2):S14-S20.
To determine effectiveness and costs of different guideline dissemination and implementation strategies.
MEDLINE (1966 to 1998), HEALTHSTAR (1975 to 1998), Cochrane Controlled Trial Register (4th edn 1998), EMBASE (1980 to 1998), SIGLE (1980 to 1988), and the specialized register of the Cochrane Effective Practice and Organisation of Care group.
Randomized-controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series evaluating guideline dissemination and implementation strategies targeting medically qualified health care professionals that reported objective measures of provider behavior and/or patient outcome. Two reviewers independently abstracted data on the methodologic quality of the studies, characteristics of study setting, participants, targeted behaviors, and interventions. We derived single estimates of dichotomous process variables (e.g., proportion of patients receiving appropriate treatment) for each study comparison and reported the median and range of effect sizes observed by study group and other quality criteria.
We included 309 comparisons derived from 235 studies. The overall quality of the studies was poor. Seventy-three percent of comparisons evaluated multifaceted interventions. Overall, the majority of comparisons (86.6%) observed improvements in care; for example, the median absolute improvement in performance across interventions ranged from 14.1% in 14 cluster-randomized comparisons of reminders, 8.1% in 4 cluster-randomized comparisons of dissemination of educational materials, 7.0% in 5 cluster-randomized comparisons of audit and feedback, and 6.0% in 13 cluster-randomized comparisons of multifaceted interventions involving educational outreach. We found no relationship between the number of components and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data.
Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities.
PMCID: PMC2557130  PMID: 16637955
practice guideline; systematic review; implementation research.
7.  How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice 
The accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.
A descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.
405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.
There are considerable gaps with implementation of evidence to support management of perineal trauma.
PMCID: PMC3472238  PMID: 22731799
Perineal trauma; Episiotomy; Suturing methods; Maternal morbidity; Midwifery practice
8.  Clinical guidelines for postpartum women and infants in primary care–a systematic review 
While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.
PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.
Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.
Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.
PMCID: PMC3906750  PMID: 24475888
Postpartum care; Clinical guidelines; AGREE II; Maternal health; Infant health
9.  Using the objective structured clinical examinations in undergraduate midwifery students  
Journal of Medicine and Life  2013;6(1):76-79.
The Objective Structured Clinical Examination (OSCE) has been considered a modern type of examination for the assessment of clinical skills within nurse education, but it has been rarely applied in the teaching of midwifery. The aim of the present study was to assess the use of the OSCE as a tool to evaluate the abilities of undergraduate midwifery students and to compare the perspectives of the students regarding the OSCE and traditional examination. Fifty-two midwifery students participated in the study. The export trainer evaluated the internal consistency of the OSCE stations and it was tested by using Cronbach’s alpha. Successive groups of students completed a self-administered questionnaire immediately after the final examination. The students’ perspective regarding the traditional final examination ranked as unsatisfactory by more than two thirds of the students, while, the students’ perspective regarding the OSCE system was ranked as very satisfactory to satisfactory by more than half of the students (p=0.001). There was a significant difference in the students’ perspective between the OSCE system and the traditional final examination among the students (49.8±18.3 vs 25.3±18.1) (p=0.001). A significant difference was found in being credible (p=0.0001), consistent/reliable (p=0.001), enhances teaching level (p=0.011), and measures the course category (p=0.008) between two methods of the final examination. Around half of the students expressed their opinion that the OSCE test was a stressful assessment. Overall, students’ evaluation of the OSCE was remarkably encouraging. To this end, we recommend the consideration of the validity and reliability of the process for undergraduate midwifery students.
PMCID: PMC3624653  PMID: 23599825
midwifery education program; educational measurement; objective assessment; program evaluation
10.  Comparison of international guideline programs to evaluate and update the Dutch program for clinical guideline development in physical therapy 
Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program.
Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program.
Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update.
Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria.
Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved.
As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program.
PMCID: PMC2228296  PMID: 18036215
11.  Diagnostic accuracy of an integrated respiratory guideline in identifying patients with respiratory symptoms requiring screening for pulmonary tuberculosis: a cross-sectional study 
To evaluate the diagnostic accuracy of the integrated Practical Approach to Lung Health in South Africa (PALSA) guideline in identifying patients requiring bacteriological screening for tuberculosis (TB), and to determine which clinical features best predict suspected and bacteriologically-confirmed tuberculosis among patients with respiratory symptoms.
A prospective, cross-sectional study in which 1392 adult patients with cough and/or difficult breathing, attending a primary care facility in Cape Town, South Africa, were evaluated by a nurse using the guideline. The accuracy of a nurse using the guideline to identify TB suspects was compared to that of primary care physicians' diagnoses of (1) suspected TB, and (2) proven TB supported by clinical information and chest radiographs.
The nurse using the guideline identified 516 patients as TB suspects compared with 365 by the primary care physicians, representing a sensitivity of 76% (95% confidence interval (CI) 71%–79%), specificity of 77% (95% CI 74%–79%), positive predictive value of 53% (95% CI 49%–58%), negative predictive value of 90% (95% CI 88%–92%), and area under the receiver operating characteristic curve (ARUC) of 0.76 (95% CI 0.74–0.79). Sputum results were obtained in 320 of the 365 primary care physicians TB suspects (88%); 40 (13%) of these were positive for TB. Only 4 cases were not identified by the nurse using the guideline. The primary care physicians diagnostic accuracy in diagnosing bacteriologically-confirmed TB (n = 320) was as follows: sensitivity 90% (95% CI 76%–97%), specificity 65% (95% CI 63%–68%), negative predictive value 7% (95% CI 5%–10%), positive predictive value 99.5% (95% CI 98.8%–99.8%), and ARUC 0.78 (95% CI 0.73–0.82). Weight loss, pleuritic pain, and night sweats were independently associated with the diagnosis of bacteriologically-confirmed tuberculosis (positive likelihood ratio if all three present = 16.7, 95% CI 5.9–29.4).
The PALSA guideline is an effective screening tool for identifying patients requiring bacteriological screening for pulmonary tuberculosis in this primary care setting. This supports the randomized trial finding that use of the guideline increased TB case detection.
PMCID: PMC1569870  PMID: 16934140
12.  Quality of Clinical Practice Guidelines for Glycemic Control in Type 2 Diabetes Mellitus 
PLoS ONE  2013;8(4):e58625.
Several studies have reported that clinical practice guidelines (CPGs) in a variety of clinical areas are of modest or variable quality. The objective of this study was to evaluate the quality of an international cohort of CPGs that provide recommendations on pharmaceutical management of glycemic control in patients with type 2 diabetes mellitus (DM2).
Methods and Findings
We searched the National Guideline Clearinghouse (NGC) on February 15th and June 4th, 2012 for CPGs meeting inclusion criteria. Two independent assessors rated the quality of each CPG using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. Twenty-four guidelines were evaluated, and most had high scores for clarity and presentation. However, scope and purpose, stakeholder involvement, rigor of development, and applicability domains varied considerably. The majority of guidelines scored low on editorial independence, and only seven CPGs were based on an underlying systematic review of the evidence.
The overall quality of CPGs for glycemic control in DM2 is moderate, but there is substantial variability among quality domains within and across guidelines. Guideline users need to be aware of this variability and carefully appraise and select the guidelines that they apply to patient care.
PMCID: PMC3618153  PMID: 23577058
13.  Modifying dyspepsia management in primary care: a cluster randomised controlled trial of educational outreach compared with passive guideline dissemination. 
BACKGROUND: Quality improvement initiatives in health services rely upon the effective introduction of clinical practice guidelines. However, even well constructed guidelines have little effect unless supported by dissemination and implementation strategies. AIM: To test the effectiveness of 'educational outreach' as a strategy for facilitating the uptake of dyspepsia management guidelines in primary care. DESIGN OF STUDY: A pragmatic, cluster-randomised controlled trial of guideline introduction, comparing educational outreach with postal guideline dissemination alone. SETTING: One-hundred and fourteen general practices (233 general practitioners) in the Salford and Trafford Health authority catchment area in the northwest of England. METHOD: All practices received guidelines by post in July 1997. The intervention group practices began to receive educational outreach three months later. This consisted of practice-based seminars with hospital specialists at which guideline recommendations were appraised, and implementation plans formulated. Seminars were followed up with 'reinforcement' visits after a further 12 weeks. Outcome measures were: (a) the appropriateness of referral for; and (b) findings at, open access upper gastrointestinal endoscopy; (c) costs of GP prescriptions for acid-suppressing drugs, and (d) the use of laboratory-based serological tests for Helicobacter pylori. Data were collected for seven months before and/or after the intervention and analysed by intention-to-treat. RESULTS: (a) The proportion of appropriate referrals was higher in the intervention group in the six-month post-intervention period (practice medians: control = 50.0%, intervention = 63.9%, P < 0.05); (b) the proportion of major findings at endoscopy did not alter significantly; (c) there was a greater rise in overall expenditure on acid-suppressing drugs in the intervention as compared with the control group (+8% versus +2%, P = 0.005); and (d) the median testing rate per practice for H pylori in the post-intervention period was significantly greater in the intervention group (four versus O, P < 0.001). CONCLUSION: This study suggests that educational outreach may be more effective than passive guideline dissemination in changing clinical behaviour. It also demonstrates that unpredictable and unanticipated outcomes may emerge.
PMCID: PMC1314507  PMID: 12817353
14.  Investigating the efficiency of nursing education program from the perspective of graduate students of nursing and midwifery 
Continuous evaluation is required in order to ensure the university system’s efficiency. One of the important aspects of evaluating the educational system’s effectiveness is judging the system’s ability in meeting environmental needs. The present research’s goal has been to investigate nursing education’s efficiency through investigating the graduate’s condition and their views on education and studying in Isfahan University’s School of Nursing and Midwifery in 2008.
Materials and Methods:
This is a descriptive research which has investigated the nursing graduate’s view on the nursing education efficiency. The sample of the present research contains one hundred graduates between the years 2001 and 2005 which have been chosen randomly to complete the questionnaire. The questionnaire is divided into five sections including; growth, demographic information, and satisfaction with professional development and the acquired scientific experiences during the education. The criteria of achieving educational goals, and acquiring individual and social development were used to determine the content of the questionnaire. Through further examination the validity of the questionnaire was calculated to be 0.85. The final analysis was done using the SPSS statistics software.
The majority of the participants were female and with an age range of 24 to 30. Among these, 55% were unemployed and 67% of them had no education higher than a bachelor degree. The mean scores of each of the efficiency fields were as following (the total score was 4): Professional growth 2.13 ± 0.36, Satisfaction with the obtained scientific achievement during studies 2.80 ± 0.48, achievement of the educational objectives1.95 ± 0.51 and individual and social improvement 2.70 ± 0.36, neither of which are desirable. There was no significant difference between the demographic information and education efficiency index.
Considering the results of the present research, the nursing education system’s efficiency level in Isfahan University is medium. Acquiring the educational goals is not satisfactory for the students. According to the results of this research, some changes have been suggested to change the lesson plans.
PMCID: PMC3702148  PMID: 23833628
Nursing education; program efficiency; professional development; objectives; satisfaction
15.  Development of a Nursing Practice Guideline for Pre and Post-Operative Care of Gastric Cancer Patients 
Healthcare Informatics Research  2010;16(4):215-223.
The aim of this study was to develop nursing practice guidelines and algorithms for the pre- and postoperative care of gastric cancer patients.
The guidelines and algorithms were developed based on a literature review and subject-matter experts' knowledge. The usefulness and applicability of the developed guidelines and algorithms were evaluated by the expert group.
The guidelines comprised 64 recommendations and algorithms for admission care, preoperative care on the day before the operation, preoperative care on the operation day, immediate postoperative assessment, postoperative care, and discharge care of gastric cancer patients. After appropriate evaluation, the experts declared the guidelines to be both useful and applicable.
The guidelines developed in this study can be used for patient care and for training nursing students and novice nurses. In addition, these guidelines can be integrated into the electronic nursing record system for clinical decision support in the future. This will improve the quality of clinical nursing and the expertise of nurses.
PMCID: PMC3092132  PMID: 21818441
Clinical Practice Guidelines; Gastric Cancer Patients; Preoperative Care; Postoperative Care
16.  Prevalence of needle stick injuries among dental, nursing and midwifery students in Shiraz, Iran 
Background: The risk of occupational exposure to blood borne pathogens (including hepatitis B, hepatitis C and HIV) via sharp injuries such as needle stick injuries (NSIs) among health care workers, especially dental, nursing and midwifery students is a challenging issue. Inadequate staff, lack of experience, insufficient training, duty overload and fatigue may lead to occupational sharp injuries. The aim of this prospective cross-sectional study was to evaluate the frequency of NSIs in Iranian dental, nursing, and midwifery students and their knowledge, attitude and practices regarding prevention of NSIs.
Methods: A questionnaire was provided to 264 dental and 435 nursing and midwifery students during their under graduate clinical training. 52% of dental students and 48% of nursing and midwifery students responded to the questionnaire. The questionnaire was pre-tested for reliability on 9.2% of the 55 sample population and found to have a high (r=0.812) test-retest reliability.
Results: 73% of students reported at least one NSI during the past year. Activities most frequently associated with injuries involved use of a hollow-bore needle during venous sampling or IV injection in both groups, followed by wound suturing in nursing and midwifery students and recapping in dental students. NSIs and non-reporting of NSIs were highly prevalent in these participants. The reason for not reporting injuries included not knowing the reporting mechanism or not knowing to whom to report.
Conclusion: Education about transmission of blood borne infections, standard precaution and increasing availability of protective strategies must be enforced. Furthermore, an optimization of the management for reporting is warranted.
PMCID: PMC3334953  PMID: 22558039
needle stick injury; nursing students; midwifery students; blood borne viruses; dental students
17.  Comparison of international breast cancer guidelines: are we globally consistent? Cancer Guideline AGREEment 
Current Oncology  2012;19(3):e184-e190.
Evidence-based guidelines are used in health care systems throughout the world to aid in treatment decisions and to ensure quality and consistency in patient care. In breast oncology, guidelines for care are published by several internationally recognized organizations, including those from the United States, Canada, and the United Kingdom. The present study compared clinical breast cancer guidelines from the American Society of Clinical Oncology (asco, United States), Cancer Care Ontario (cco, Canada), and the National Institute for Health and Clinical Excellence (nice, United Kingdom) to determine the quality and consistency of content across international organizations.
We searched for breast cancer guidelines published by asco, cco, and nice. Guidelines on the same theme were identified across organizations and appraised by 4 independent reviewers using the Appraisal of Guidelines for Research and Evaluation (agree) instrument. Content of each guideline was also scored for consistency in overall recommendations across organizations and for consistency in cited evidence.
The quality of breast cancer guidelines produced by the targeted organizations was consistently good in the areas of Scope and Purpose, Rigor of Development, and Clarity and Presentation, but variable in the domains of Stakeholder Involvement, Applicability, and Editorial Independence. The content of the guidelines varied slightly in the strength of their recommendations.
Our review demonstrated consistency in quality and content for breast cancer practice guidelines published by various organizations. Future guidelines developed by these organizations should focus on how to implement and measure uptake of a guideline.
PMCID: PMC3364779  PMID: 22670108
Breast cancer; practice guidelines; agree instrument; quality of care
18.  Evaluation of an online interactive Diabetes Needs Assessment Tool (DNAT) versus online self-directed learning: a randomised controlled trial 
BMC Medical Education  2011;11:35.
Methods for the dissemination, understanding and implementation of clinical guidelines need to be examined for their effectiveness to help doctors integrate guidelines into practice. The objective of this randomised controlled trial was to evaluate the effectiveness of an interactive online Diabetes Needs Assessment Tool (DNAT) (which constructs an e-learning curriculum based on individually identified knowledge gaps), compared with self-directed e-learning of diabetes guidelines.
Health professionals were randomised to a 4-month learning period and either given access to diabetes learning modules alone (control group) or DNAT plus learning modules (intervention group). Participants completed knowledge tests before and after learning (primary outcome), and surveys to assess the acceptability of the learning and changes to clinical practice (secondary outcomes).
Sixty four percent (677/1054) of participants completed both knowledge tests. The proportion of nurses (5.4%) was too small for meaningful analysis so they were excluded. For the 650 doctors completing both tests, mean (SD) knowledge scores increased from 47.4% (12.6) to 66.8% (11.5) [intervention group (n = 321, 64%)] and 47.3% (12.9) to 67.8% (10.8) [control group (n = 329, 66%)], (ANCOVA p = 0.186). Both groups were satisfied with the usability and usefulness of the learning materials. Seventy seven percent (218/284) of the intervention group reported combining the DNAT with the recommended reading materials was "very useful"/"useful". The majority in both groups (184/287, 64.1% intervention group and 206/299, 68.9% control group) [95% CI for the difference (-2.8 to 12.4)] reported integrating the learning into their clinical practice.
Both groups experienced a similar and significant improvement in knowledge. The learning materials were acceptable and participants incorporated the acquired knowledge into practice.
Trial registration
PMCID: PMC3130714  PMID: 21679446
19.  Midwifery care, social and medical risk factors, and birth outcomes in the USA 
STUDY OBJECTIVE: To determine if there are significant differences in birth outcomes and survival for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain after controlling for sociodemographic and medical risk factors. DESIGN: Logistic regression models were used to examine differences between certified nurse midwife and physician delivered births in infant, neonatal, and postneonatal mortality, and risk of low birthweight after controlling for a variety of social and medical risk factors. Ordinary least squares regression models were used to examine differences in mean birthweight after controlling for the same risk factors. STUDY SETTING: United States. PATIENTS: The study included all singleton, vaginal births at 35-43 weeks gestation delivered either by physicians or certified nurse midwives in the United States in 1991. MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births. CONCLUSIONS: National data support the findings of previous local studies that certified nurse midwives have excellent birth outcomes. These findings are discussed in light of differences between certified nurse midwives and physicians in prenatal care and labour and delivery care practices. Certified nurse midwives provide a safe and viable alternative to maternity care in the United States, particularly for low to moderate risk women.
PMCID: PMC1756707  PMID: 9764282
20.  Randomised controlled trial of the impact of guidelines, prioritized review criteria and feedback on implementation of recommendations for angina and asthma. 
BACKGROUND: Guidelines are frequently used in an attempt to influence the performance of health professionals, and a national agency has been established in England and Wales to develop and disseminate guidelines. Professionals prefer short guidelines that highlight key recommendations, but whether such guidelines are more likely to be implemented is unknown. AIM: To determine the relative impact of the dissemination of full guidelines, reduced guidelines in the form of prioritized review criteria, and review criteria supplemented by feedback. DESIGN OF STUDY: Cluster randomised controlled trial, with an incomplete block design. SETTING: Eighty-one general practices in Leicestershire, Lincolnshire, Northamptonshire, North Derbyshire, and Nottinghamshire. METHOD: The practices received one of the study interventions, either for care of adults with asthma or for care of people with angina. Data were collected before and after the interventions, the process measures being adherence to ten recommendations about asthma and 14 about angina, and outcome measures being scores in response to an asthma symptom questionnaire or the Seattle Angina Questionnaire, and levels of patient satisfaction. RESULTS: There were no consistent differences between the interventions in stimulating improvements in performance as indicated by adherence to the recommendations for asthma or angina. Patients with angina in practices that had received criteria or criteria plus feedback reported better symptom control. CONCLUSION: The dissemination of guidelines in the format of prioritized review criteria does not increase adherence to recommendations in comparison with the traditional guideline format, and the further provision of feedback has minimal additional effect.
PMCID: PMC1314570  PMID: 12879828
21.  A cluster randomised controlled trial of nurse and GP partnership for care of Chronic Obstructive Pulmonary Disease 
Chronic obstructive pulmonary disease (COPD) is a significant health problem worldwide. This randomised controlled trial aims at testing a new approach that involves a registered nurse working in partnership with patients, general practitioners (GPs) and other health professionals to provide care to patients according to the evidence-based clinical practice guidelines. The aim is to determine the impact of this partnership on the quality of care and patient outcomes.
A cluster randomised control trial design was chosen for this study. Randomisation occurred at practice level. GPs practising in South Western Sydney, Australia and their COPD patients were recruited for the study.
The intervention was implemented by nurses specifically recruited and trained for this study. Nurses, working in partnership with GPs, developed care plans for patients based on the Australian COPDX guidelines. The aim was to optimise patient management, improve function, prevent deterioration and enhance patient knowledge and skills. Control group patients received 'usual' care from their GPs.
Data collection includes patient demographic profiles and their co-morbidities. Spirometry is being performed to assess patients' COPD status and CO analyser to validate their smoking status. Patients' quality of life and overall health status are being measured by St George's Respiratory Questionnaire and SF-12 respectively. Other patient measures being recorded include health service use, immunisation status, and knowledge of COPD. Qualitative methods will be used to explore participants' satisfaction with the intervention and their opinion about the value of the partnership.
Analysis will be by intention to treat. Intra-cluster (practice) correlation coefficients will be determined and published for all primary outcome variables to assist future research. The effect of the intervention on outcomes measured on a continuous scale will be estimated and tested using mixed model analysis of variance in which time and treatment group will be fixed effects and GP practice and subject nested within practice will be random effects. The effect of the intervention on the dichotomous variables (such as smoking status, patient knowledge) will be analysed using generalised estimating equations with a logistic link and a model structure that is analogous to that described above.
Trial registration
PMCID: PMC2442044  PMID: 18519003
22.  Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review 
Electronic guideline-based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines. A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services.
A systematic literature search (1990 to December 2008) of the English literature indexed in the Medline database, Embase, the Cochrane Central Register of Controlled Trials, and CRD (DARE, HTA and NHS EED databases) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care settings. Important inclusion criterions were the multidimensionality of the guideline (the guideline needed to consist of several aspects or steps) and real-time interaction with the system during consultation. Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier reviews were excluded. Two comparisons were considered: electronic multidimensional guidelines versus usual care (comparison one) and electronic multidimensional guidelines versus other guideline implementation methods (comparison two).
Twenty-seven publications were selected for analysis in this systematic review. Most designs were cluster randomized controlled trials investigating process outcomes more than patient outcomes. With success defined as at least 50% of the outcome variables being significant, none of the studies were successful in improving patient outcomes. Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group (comparison one). No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found, neither for the patient outcomes nor for the process outcomes (comparison two).
There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines. After more than a decade of development of numerous electronic systems, research on the most effective implementation strategy for this kind of guideline-based decision support systems is still lacking. This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care.
PMCID: PMC2806389  PMID: 20042070
23.  Evaluation of current care effectiveness: A survey of hypertension guideline implementation in Finnish health centres 
To assess the extent and style of implementation of the Hypertension Guideline (HT Guideline) in Finnish primary health centres, and to identify a scale of contrasting implementation styles in the health centres (with the two ends of the scale being referred to as information implementers or disseminators respectively).
A cross-sectional study. Development of a questionnaire and criteria for assessing the extent and style of implementation of the HT Guideline.
Primary healthcare.
All head physicians and senior nursing officers in Finnish health centres (n =290).
Main outcome measures
The extent of adoption of the HT Guideline in health centres and the characteristics associated with the implementation style.
Responses were received from 410 senior medical staff (246 senior nursing officers and 164 head physicians) representing altogether 264 health centres (91%) in Finland. The HT Guideline had been introduced into clinical practice in most health centres (89%). The style of implementation varied widely between health centres: at opposite ends of the implementation scale were 21 implementer health centres, which used multiple implementation channels, and 23 disseminator health centres, which used few or no implementation channels. The implementers had typically larger population bases and had organized services around the family doctor system, while the disseminators were smaller and had organized services according to a traditional model (appointments could be with any doctor in the surgery).
The Finnish HT Guideline has become well known in most health centres since being introduced into clinical practice. However, the style of implementation varies markedly between health centres.
PMCID: PMC3379765  PMID: 17852969
Clinical practice guidelines; family practice; hypertension; implementation; primary health care
24.  Nursing and midwifery regulation and HIV scale-up: establishing a baseline in east, central and southern Africa 
Shifting HIV treatment tasks from physicians to nurses and midwives is essential to scaling-up HIV services in sub-Saharan Africa. Updating nursing and midwifery regulations to include task shifting and pre-service education reform can help facilitate reaching new HIV targets. Donor-supported initiatives to update nursing and midwifery regulations are increasing. However, there are gaps in our knowledge of current practice and education regulations and a lack of information to target and implement regulation strengthening efforts. We conducted a survey of national nursing and midwifery councils to describe current nursing and midwifery regulations in 13 African countries.
A 30-item survey was administered to a convenience sample of 13 national nursing and midwifery regulatory body leaders in attendance at the PEPFAR-supported African Health Profession Regulatory Collaborative meeting in Nairobi, Kenya on 28 February, 2011. The survey contained questions on task shifting and regulations such as registration, licensure, scope of practice, pre-service education accreditation, continuing professional development and use of international guidelines. Survey data were analyzed to present country-level, comparative and regional findings.
Task shifting to nurses and midwives was reported in 11 of the 13 countries. Eight countries updated their scope of practice within the last five years; only one reported their regulations to reflect task shifting. Countries vary with regard to licensure, pre-service accreditation and continuing professional development regulations in place. There was no consistency in terms of what standards were used to design national practice and education regulations.
Many opportunities exist to assist countries to modernise regulations to incorporate important advancements from task shifting and pre-service reform. Appropriate, revised regulations can help sustain successful health workforce strategies and contribute to further scale-up HIV services and other global health priorities.
This study provides fundamental information from which to articulate goals and to measure the impact of regulation strengthening efforts.
PMCID: PMC3608854  PMID: 23531276
human resources for health; task shifting; task sharing; HIV; AIDS; scale-up; pre-service; nurse-initiated ART
25.  Public health interventions in midwifery: a systematic review of systematic reviews 
BMC Public Health  2012;12:955.
Maternity care providers, particularly midwives, have a window of opportunity to influence pregnant women about positive health choices. This aim of this paper is to identify evidence of effective public health interventions from good quality systematic reviews that could be conducted by midwives.
Relevant databases including MEDLINE, Pubmed, EBSCO, CRD, MIDIRS, Web of Science, The Cochrane Library and Econlit were searched to identify systematic reviews in October 2010. Quality assessment of all reviews was conducted.
Thirty-six good quality systematic reviews were identified which reported on effective interventions. The reviews were conducted on a diverse range of interventions across the reproductive continuum and were categorised under: screening; supplementation; support; education; mental health; birthing environment; clinical care in labour and breast feeding. The scope and strength of the review findings are discussed in relation to current practice. A logic model was developed to provide an overarching framework of midwifery public health roles to inform research policy and practice.
This review provides a broad scope of high quality systematic review evidence and definitively highlights the challenge of knowledge transfer from research into practice. The review also identified gaps in knowledge around the impact of core midwifery practice on public health outcomes and the value of this contribution. This review provides evidence for researchers and funders as to the gaps in current knowledge and should be used to inform the strategic direction of the role of midwifery in public health in policy and practice.
PMCID: PMC3544621  PMID: 23134701
Systematic review; Public health; Midwife; Pregnancy

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