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Refereed/Peer-reviewed Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers’ evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as ‘a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments’. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress.

Resilience is considered a vital characteristic and has gained attention in midwifery practice and education. In particular, midwifery students face challenges during their education in both academic and clinical components of the program. There is need for greater understanding and strategies to develop resilience in the midwifery student population. The aim of this study is to gain insight into how midwifery students conceptualise resilience, and explore how education might support the development of resilience. A focus group was conducted as part of a broader study underpinned by a concept analysis methodology to explore the students understanding of resilience. Participants included six third year midwifery students from one university. Thematic analysis was used to analyse the data. Four key themes were identified. Resilience contextualised to midwifery was triggered by exposure to adversity; resilience was identified as the ability to bounce back and move forward, and was seen to be important for midwifery students. The concept of resilience appears to play an important role in student success. Evidence suggests resilience can be developed and education providers have a role to foster student's resilience. Findings offer strategies to strengthen resilient behaviour for the midwifery student population and provide a basis for further research. Refereed/Peer-reviewed

Problem Australian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice. Background Moral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals’ moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice. Aim To explore Australian midwives experience and consequences of moral distress. Methods Semi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©. Findings Three key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care. Discussion It is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding. Conclusion This study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced.

Clinical placement is a core feature of Australian midwifery education programs, with clinical supervision acknowledged as a key component for student success. The aim of this study was to evaluate the clinical facilitation models in South Australia, specifically the quality of clinical supervision to facilitate learning, and key stakeholder satisfaction. A mixed method evaluation research design was used to compare three models of clinical facilitation for midwifery students undertaking clinical placement across five venues. Midwifery students (n = 174), across two universities completed an anonymous e-survey utilising the validated Clinical Placement Experience Questionnaire. Midwives (n = 149) across five venues completed an anonymous purpose-designed questionnaire on their experience providing clinical supervision to midwifery students and Clinical Facilitators (n = 8) representing three facilitation models completed a self-report e-diary for two weeks and engaged in a focus group. Few differences were identified between the quality of student support and learning opportunities. Students in all models were well orientated and prepared for the clinical environment. Clinical Facilitators were supportive, educative and valuable for the students to achieve their learning objectives. One significant difference was that facilitators employed in the ‘Shared’ model were more able to provide support to midwives supervising students and maintain good liaison with the universities. Refereed/Peer-reviewed

Background The effect that the route of maternal fentanyl administration has on placental transfer of drug to the neonate is not well studied. Plasma concentration ratios are an indicator of fetal exposure, relative to the mother. Method A cohort study (n=30) was conducted to measure fentanyl concentrations in maternal plasma, and arterial and venous cord blood, among women administered with either intranasal or subcutaneous fentanyl for labour pain relief. Maternal and cord blood samples were collected within 30 min of birth to determine the fentanyl plasma concentration and to assess relative neonatal exposure. Neonatal outcomes were assessed by Apgar scores, need for resuscitation and nursery admission. The study was registered as ACTRN12618001012268. Results Thirty paired samples were obtained from healthy parturients with uncomplicated term pregnancies. Highest observed umbilical venous and arterial concentrations were 0.71 ng/mL and 0.56 ng/mL, respectively, and fetal to maternal fentanyl plasma concentration ratios ranged between 0.23 and 0.73, indicating low fetal exposure. While the total intranasal fentanyl dose administered was significantly higher than the subcutaneous fentanyl dose, this did not result in a higher fetal to maternal ratio. All neonates in both groups had 5-min Apgar scores >7, two neonates required short term stimulation and oxygen (unrelated to fentanyl) and no neonate was admitted to the nursery. Conclusion This study is the first to examine fetal and maternal fentanyl concentrations after subcutaneous administration. This research supports the safe use of fentanyl for labour analgesia for women.

Undergraduate midwifery programs across Australia have embedded simulation into their curriculum although there is limited but emerging evidence to support the use of simulation as an effective teaching strategy. The purpose of this study was to evaluate the impact that a simulated learning activity (insertion and management of a neonatal nasogastric tube), had on midwifery students' knowledge, confidence and skills post-simulation, and on completion of a clinical placement. A descriptive explorative study was undertaken in two phases. Phase 1: Midwifery students (n = 60) completed a purpose-designed questionnaire to assess their knowledge, confidence and skills, pre and post simulation. Phase 2: Students (n = 46) repeated the questionnaire to reassess their knowledge, confidence and skills after the completion of a neonatal nursery placement. The findings demonstrate that simulation is an effective learning strategy in an undergraduate midwifery program. Students' knowledge, confidence and skills increased significantly post-simulation activity (p0.001). A further increase in these areas was noted post-placement. Key aspects that contributed to student learning included; the demonstrators’ level of knowledge, expertise and currency of practice, as well as the role the student assumes in the simulation activity. usc Refereed/Peer-reviewed

Background: Shared decision making in pregnancy, labour, and birth is vital to woman-centred care and despite strong evidence for the effectiveness of shared decision making in pregnancy care, practical uptake has been slow. Design and Aim: This scoping review aimed to identify and describe effective and appropriate shared decision aids designed to be provided to women in the antenatal period to assist them in making informed decisions for both pregnancy and birth. Two questions guided the enquiry: (i) what shared decision aids for pregnancy and perinatal care are of appropriate quality and feasibility for application in Australia? (ii) which of these decision aids have been shown to be effective and appropriate for Aboriginal and Torres Strait Islander peoples, culturally diverse women, or those with low literacy? Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) was used to conduct the review. Five key databases and selected grey literature sources were examined. English language evidence from Australia, Europe, Canada, United Kingdom, New Zealand, and United States of America produced from 2009 was eligible for inclusion, checked against apriori inclusion criteria, and assessed for quality and usability using the International Patient Decision Aid Standards. Results: From a total of 5,209 search results, 35 sources of evidence reporting on 27 decision aids were included following title/abstract and full-text review. Most of the decision aids concerned decisions around birth (52%, n = 14) or antenatal screening 37% (n = 10). The quality of the decision aids was moderate to high, with most communicating risks, benefits, and choice pathways via a mix of Likert-style scales, quizzes, and pictures or graphs. Use of decision aids resulted in significant reductions in decisional conflict and increased knowledge. The format of decision aids appeared to have no effect on these outcomes, indicating that paper-based are as effective as video- or audio-based decision aids. Eleven decision aids were suitable for low literacy or low health literacy women, and six were either developed for culturally diverse groups or have been translated into other languages. No decision aids found were specific to Aboriginal and Torres Strait Islander peoples. Conclusions and implications for practice: The 27 decision aids are readily adoptable into westernised healthcare settings and can be used by midwives or multidisciplinary teams in conjunction with women. Decision aids are designed to support women, and families to arrive at informed choices and supplement the decision-making process rather than to replace consumer-healthcare professional interaction. If given before an appointment, high quality decision aids can increase a woman's familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflict and increasing knowledge. Refereed/Peer-reviewed

It’s more than just luck: A qualitative exploration of breastfeeding in rural Australia Problem Despite significant public health benefits, breastfeeding for six months continues to be challenging for women. Background In the Mid North of South Australia, healthcare professionals were concerned that breastfeeding rates were lower than the national average and that a collaborative approach was needed to promote breastfeeding. Aim To explore the experiences of women and health professional in the Mid North, to inform interventions to improve breastfeeding longevity. Method Two focus groups were conducted to examine breastfeeding experience in the region. Focus group one included nine mothers who had breastfed more than six months and focus group two consisted of ten health professionals from the Mid North. Thematic analysis was used to analyse the data. Findings Two overarching themes were identified; ‘breastfeeding: It’s more than just luck’ represented the voices of the mothers and ‘breastfeeding: It’s everybody’s business’ captured the discussion between the health professionals. Women described themselves as lucky while acknowledging that their own persistence, as well as positive support was vital. Health professionals identified education and support as key foci, and a need for a holistic approach to improve breastfeeding rates. Discussion Breastfeeding should be understood as a relationship, in which broadly applied solutions do not necessarily influence longevity, particularly in rural communities. Strategies should also reflect a realistic picture of breastfeeding and safeguard against idealistic expectation of the experience. Conclusion A holistic approach to improve breastfeeding rates is imperative. One of the most promising antidotes to the breastfeeding dilemma is the provision of midwifery continuity of care.

Background: Nutrition and healthy eating behaviors during pregnancy are vitally important for the health of a mother and her developing baby. However, some midwives have reported a lack of evidence-based nutrition knowledge for providing information about healthy eating to women during pregnancy. Objective: In this study, the aim is to design and evaluate a healthy eating education program to enhance midwives’ knowledge, understanding, and confidence to support pregnant women in South Australia to make healthy eating choices. Methods: This mixed-methods study consists of two phases. The first phase, Phase 1, consists of an education program for midwives, “Healthy Eating in Pregnancy,” to be delivered through a workshop or webinar. Each midwife will attend one workshop or webinar, which will be approximately two hours in length. This program will be evaluated through pre-, immediate-, and post-educational questionnaires utilizing a website specifically designed for this study. The participants will be midwives who are members of the Australian College of Midwives and the Australian Nursing and Midwives Federation, and users of social media (eg, Facebook and Twitter) residing and employed in South Australia. Phase 2 will consist of semistructured interviews with a purposive sample of midwives. These interviews will be undertaken to gain an in-depth understanding of midwives’ views and how confident they feel educating pregnant women after receiving the healthy eating education. Interviews will be face-to-face or conducted by telephone with midwives who have participated in the healthy eating educational program. Results: A systematic review has previously been undertaken to inform this study protocol. This paper describes and discusses the protocol for this mixed-methods study, which will be completed in April 2019. Conclusions: The results from the systematic review suggest that there is clear justification to undertake this mixed-methods study to investigate and explore midwives’ knowledge, understanding and confidence to support healthy eating in pregnant women. The results and conclusions from the systematic review provided some guidance for the design and development of this study protocol. This mixed-methods study will address a gap in the literature. The results from quantitative and qualitative data sources in this proposed study will help to draw conclusions to address the research topic. Registered Report Identifier: RR1-10.2196/9861

Objective to explore the maternal and neonatal effects of fentanyl administered subcutaneously to women during labour. Design two methods were used: (1) A retrospective audit of the birth register and maternal and neonatal records for the period from January 2000 to December 2007. (2) A pilot study was also conducted on a convenience sample of women between July 2008 and October 2008 Setting this study was conducted within a maternity unit at a rural South Australian hospital where approximately 350 babies are birthed each year. Participants audit participants included women who had uncomplicated pregnancies and birthed at term (37–42 weeks gestation). Women in the experimental group consisted of those who had utilised only subcutaneous fentanyl for pain relief (n=75), or nitrous oxide and oxygen prior to being administered subcutaneous fentanyl (n=196). Stratified random selection based on parity and age was used to determine the control group, which consisted of women who used no pharmacological pain relief (n=196). The pilot study involved a convenience sample of women (n=10) assessed to have an uncomplicated pregnancy and labour occurring at term (≥37 weeks gestation). Measurements audit variables examined included the women's age, parity, labour duration, mode of birth (spontaneous or assisted), analgesia used, total dosage, time administered prior to birth, time of birth, neonatal Apgar scores, time to establish breathing, naloxone use, days spent in hospital post-birth and breast-feeding outcomes upon discharge. The pilot study explored maternal effects assessed pre- and 30 minutes post-administration of subcutaneously administered fentanyl by observing pain scores, vital signs, sedation levels, nausea/vomiting scores and anti-emetic use. To assess possible adverse effects in the neonate Apgar scores, time to establish respiration, naloxone use, transfer to neonatal nursery and breast-feeding outcomes upon discharge were recorded Findings women in the experimental groups were more likely to be induced, experienced a longer duration of labour and had an increased likelihood of an assisted vaginal birth. The average total dose of fentanyl administered was 250 μg. Neonatal outcomes were comparable between groups when examining Apgar scores

Objective: to investigate the use of fentanyl for pain relief during childbirth administered by routes other than epidural or spinal (non-axial). In particular, aspects relating to the efficacy and safety of fentanyl for mother and neonate are explored. Background: currently, pethidine is the most widely used intramuscular opioid for the relief of labour pain but has been shown to have numerous side-effects on the mother and neonate. An alternative opioid, fentanyl, has been shown to have fewer side-effects on both mother and neonate than pethidine. Therefore, its use during childbirth was examined in this literature review. Review methods: a search of articles relating to the administration of fentanyl via non-axial routes was conducted using electronic databases, key journals and reference lists of selected research papers and reviews. Results: only studies of IV administration were identified from the literature findings from showed that IV administered fentanyl appeared to be a safe, efficacious opioid when administered for pain relief in childbirth. Fentanyl is a short-acting analgesic causing less sedation and nausea in adults than pethidine. In addition, no long-term fetal or neonatal effects of fentanyl were identified, with normal neonatal neurological and adaptive capacities at two hours and 24 hours after birth supporting its safe use in childbirth. Key conclusion: in the studies identified, fentanyl was found to be efficacious, providing prompt analgesia with minimal side-effects to both mother and infant when administered intravenously (IV) during childbirth. In addition, no long-term fetal effects were found. Recommendations for further research: there is a paucity of research relating to the maternal, fetal and neonatal effects of non-axial administered fentanyl other than that of IV. Further research should explore alternate routes of administration such as subcutaneous, sublingual and nasal which are less invasive and can be administered by midwives. Implication for practice: in confirming the safe use of non-axial administration of fentanyl during childbirth, benefits include midwives being able to offer women an alternative option for pain relief. Alternative routes, such as subcutaneous, can be managed by midwives through a standing order, potentially reducing the need for additional resources. In particular, this will benefit midwifery practice in rural and remote settings where resources and access to specialised services are limited Refereed/Peer-reviewed

Refereed/Peer-reviewed