Nursing - Theses
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ItemWomen’s Safety During Labour and Birth: A Qualitative Study( 2022-12)Women’s safety is a key priority during labour and birth. However, preventable harm and errors in maternity care remain, resulting in life changing consequences for women and their families. Despite improved maternity care, adverse and sentinel events persist, resulting in maternity care being considered a high risk/high litigation area. To mitigate risk and litigation, organisations implement strategies to optimise women’s safety. However, what is not clear is if women’s perspectives of safety align with those of organisations that implement safety initiatives. This thesis aimed to explore the concept of safety during labour and birth from two key perspectives: that of the women and of the organisations that provide care. This study, using a multi-method qualitative design, was conducted at a large Melbourne metropolitan hospital, which provides care to women from culturally and linguistically diverse (CALD) backgrounds. Data were collected during focus groups (n = 12) and individual interviews (n = 20) with women following their birth; and individual interviews with key organisational stakeholders (n = 11), responsible for the provision of care to women during labour and birth. This study found that organisations implement a range of safety strategies. These included: clinical governance such as monitoring women’s morbidity and mortality; models of care and staff training in the area of managing emergencies. When measuring outcomes, organisations focused on physical outcomes for the mother and newborn, such as morbidity, and largely overlooked the woman’s perception of safety. In terms of safety, for the most part, there was a disparity between how women and organisations define the concept. Women define safety as a holistic construct which includes not only physical elements but spiritual, emotional, cultural and psychological elements. This definition involved a complex interplay of factors such as: communication with staff, competent staff, cultural practices and spiritual attributes. Safety was further defined as occurring on a dynamic continuum from feeling safe to feeling unsafe. Organisations define safety as a physical and operational construct, contingent on the interaction of many dynamics. These included: organisational systems and processes; communication between staff and women; and having competent staff. The importance of including women’s views was also a key factor when key stakeholders defined safety. A conceptual model on safety during labour and birth was developed using Bourdieu’s Theory of Practice. The model provides a lens for organisations to identify aspects of care which are pivotal for women when defining safety. By identifying these elements and incorporating them into how safety is operationalised, may assist with mitigating complaints, subsequent litigation claims and building safe intrapartum care. Additionally, recommendations, driven by the data, are described to inform maternity care providers about how to optimise women’s safety during labour and birth. The key recommendation centres on the need for maternity care providers to include women’s views when developing, implementing, and evaluating safety strategies during labour and birth.
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ItemExploring post-treatment care for women with high-intermediate and high-risk endometrial cancer: A mixed methods study( 2022)Endometrial cancer (EC) imposes a significant burden on women and the health system. Intense post-treatment follow-up (FU) for women with high-intermediate (H-I) and high-risk (H-R) disease lasts five years or longer with only 20% likely to develop recurrence. Death from pre-existing conditions is more likely than from EC. No evidence supports FU improving long-term survival or quality of life. Alternative FU needs consideration. The aim of this thesis was to explore current post-treatment FU models for women with H-I and H-R EC to: - Understand the current model of patient care in addressing survivorship issues. - Identify deficiencies in post-treatment care. - Make recommendations that support optimal care based on women's perspectives and needs. A sequential explanatory mixed methods study was conducted in two phases to: examine patterns of care and disease outcomes; explore the extent to which the current model of care 1) meets women’s physical and emotional needs; 2) addresses survivorship issues. Phase 1: A retrospective case audit was conducted of women referred for adjuvant radiation treatment between 2004 and 2014 who subsequently recurred. Data were analysed using descriptive statistics. Phase 2 recruited women without evidence of disease, attending medically-led FU. Purposive sampling targeted a range of experiences post-treatment. Semi-structured interviews were analysed using inductive thematic approach. Quantitative data results revealed of 786 women referred, 19% developed recurrence. Most (63%) had at least two pre-existing comorbidities. Few notes (9%) documented lifestyle discussions. A third (31%) experienced mild/moderate treatment-related side-effects. Most notes (84%) contained no references to emotional status; few (12%) contained exercise recommendations; few (17%) for those working pre-treatment indicated return to work discussions; seven documented nursing consultation. Most recurrence (87%) occurred within three years post-surgery, 70% was symptomatic. Although treating clinicians detected 59% of recurrences, only 46% were during scheduled FU. The majority (59%) had multi-focal recurrence and poor outcomes. Two years post-treatment for recurrence, 31% were alive, 15% without evidence of disease. Eleven survived four years. Analysis of 25 interviews yielded four themes: ‘The safe haven of FU’; ‘Fear of cancer recurrence’ (FOR); ‘It is more than absence of cancer’; ‘Attitudes and relationships to health care professionals’. Women reported little preparation for survivorship. FU focused on physical symptoms; recurrence detection; treatment toxicity. Attending FU both escalated and alleviated FOR. Generally emotional needs were unmet. Health promotion and practical support toward making lifestyle changes was absent. Women valued specialist-led FU and ongoing connection with them. Women perceived limited contact with nurses in FU. Nurse-led care could provide for unmet needs, including emotional and healthy lifestyle support. In conclusion, this thesis indicates the current model is effective in dealing with medical issues from a disease perspective but is inefficient. In 70% of cases recurrence detection was from symptomatic disease rather than FU. For many, the current model is burdensome and does not comprehensively address survivorship issues. Findings indicate revision of national EC FU guidelines, and reforming EC survivorship care models as needed. Shifting the focus of FU towards addressing women’s post-treatment experiences is overdue. Specialist nurse-led FU should be considered.