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Rationale: Defensive caesarean section (CS) has become one of the most common medical procedure worldwide. Additionally, performing CS in accordance with the patient's choice is an appropriate professional practice. Aims and Objective: This paper reports a prospective, observational, multicenter study to quantify the use of this type of practice that is performed by obstetricians to avoid medico‐legal complaints and decrease the frequency of malpractice litigations. Methods: We interviewed 73 obstetricians from three distinct units of obstetrics and gynaecology, to assess their opinion regarding defensive caesarean delivery and caesarean delivery performed upon maternal request. We conducted an opinion‐based survey using questionnaires based on nine, close‐ended questions. Results: Out of 73 respondents, 51 (69.9%) stated that they perform defensive CS; 63 (86.3%) declared that their choice of birth delivery is influenced by the risk of being accused of malpractice; 60 (82.2%) indicated that it is normal for the patient to be able to decide on the type of delivery; and 63 (86.3%) declared that they consult their patients regarding their delivery preferences. We found statistically significant differences between the respondents who declare that they perform defensive CS (69.9%) and those who said that they are influenced by the risk of malpractice when they choose the method of delivery for their patients (86.3%) (P < .001; McNemar Test). Conclusions: The results of our study indicate that defensive caesarean section is a widespread practice among obstetrics practitioners in Romania. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. Methods: We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. Results: The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. Conclusions: We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The shortage of kidney donors and benefits of kidney transplantation make graft success imperative. Medication adherence is critical to prevent the risk of graft rejection. This paper examines how adults are prepared and supported by renal transplant co-ordinators and pharmacists to take their medications as prescribed in kidney transplantation. Methods Renal transplant co-ordinators and pharmacists of all five hospitals offering adult kidney transplantation in Victoria, Australia, were interviewed between November 2013 and February 2014. All data underwent qualitative descriptive analysis. Results Nine renal transplant co-ordinators and six pharmacists were interviewed. Although there was no standardized approach to education or other evidence-based strategies to facilitate medication adherence, there were similarities between sites. These similarities included printed information, pre-transplant education sessions, the use of medication lists and medication administration aids, intensive education in hospital and ensuring an adequate supply of medications post-discharge. Conclusions Renal transplant co-ordinators and pharmacists recognized the importance of early patient education concerning immunosuppressant medication. However, each site had developed their own way of preparing a patient for kidney transplantation and follow-up in the acute hospital setting based on experience and practice. Other non-educational strategies involving behavioural and emotional aspects were less common. Differences in usual care reinforce the necessity for evidence-based health care for best patient outcomes. [ABSTRACT FROM AUTHOR]

Rationale: Patients with complex care needs who frequently use health services often face challenges in managing their health and with integrated care, leading to frequent decision making. These complex care needs require a good understanding of health issues and their impact on daily life. As the decisional needs of this particular clientele have yet to be described in scientific literature, they warrant further study. Objectives: To assess the decision‐making needs of patients with complex care needs (PCCN) who frequently use health care services. Methods: We performed a multicenter cross‐sectional qualitative descriptive study in four institutions of the health and social services network of Quebec (Canada). We enrolled a convenience sample of PCCNs who frequently use health care services, health care providers, case managers, and decision‐makers. We conducted interviews and focus groups and investigated decisional needs according to the Ottawa decision support framework: roles played and desired in the decision‐making process, facilitators, and barriers. We conducted qualitative data collection and qualitative deductive/inductive thematic analysis within and across participating groups. Results: In total, 16 patients, 38 clinicians, six case managers, and 14 decision‐makers participated in the study. The decisional needs of this clientele are numerous, varied and different from those of the general population. We identified 26 decisional needs grouped under five themes. The most frequent decisions related to visiting the emergency department, moving to a nursing home, and adhering to a plan or treatment. In addition, we identified new themes such as patients' fear and mistrust of health professionals, differences of opinion between health professionals and health professionals' preconceived opinions of patients. Conclusion: We observed a wide range of types of decisions that patients face and differences in decision‐making needs across participating groups. Our results should inform future research on the development of a patient decision aid tool. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Changes in Sweden's municipal care have impacted the situation of physiotherapists by the adoption of practice based on research evidence. Even if physiotherapists appear to be in favour of the idea of evidence-based practice, barriers still exist that prevent many from keeping up with current research. The aim of this study was to identify and describe the different ways in which physiotherapists in municipal care perceive the concept of evidence in rehabilitation. Methods A phenomenographic design with semi-structured interviews was carried out with physiotherapists working with frail older people in three municipal care units in two neighbouring municipalities in Sweden. The physiotherapists' perceptions of evidence were explored in 12 interviews. Results Distinct perceptions of the concept of evidence are identified in three categories: 'Confidence with the concept of evidence in relation to measurement instruments'; 'Perception of evidence-based practice as a duty, condition and demand of the profession'; and 'Evidence-based work as a separate rather than directly patient-oriented activity'. Conclusions Physiotherapists take full responsibility to comply with what they perceive to be the demands of their profession. However, what evidence actually meant, and therefore what the practical element of this responsibility consisted of, was not as clear. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Guidelines are intended as a means of getting research evidence into practice and ensuring provided care is of sufficient quality. However, the effect of guidelines is hindered by limited guideline adherence. The aim of this study is to identify and classify barriers to adherence by nurses to a guideline on delirium care. Methods Open-ended interviews were conducted with a purposive sample of 63 research participants. The sample included 28 nurses, 18 doctors and 17 policy advisors working in 19 hospitals in the Netherlands. The interviews were conducted between June and September 2011. The data were analysed using thematic analysis. Results Barriers to guideline adherence that were identified could be grouped into four themes: motivation and goals, knowledge and skills, professional role and identity, and context and resources. While the interviews with nurses, doctors and policy advisors produced similar views of the current situation, doctors and policy advisors placed a higher importance on education as a means of stimulating adherence. Conclusions This study illustrates that individual, social and organizational factors play a role in nurse's adherence to a delirium guideline. The potential benefits of following a guideline, both for patients and for nursing staff, need to be highlighted in order to motivate nurses. When formulating new guidelines, nurses' perceptions of their professional role and patient care need to be taken into account to ensure that policy makers and managers are realistic about guideline adherence and engage with nurses from a position of mutual respect and trust. [ABSTRACT FROM AUTHOR]