Objectives To explore maternity care providers’ attitudes toward regional centralisation of vaginal breech birth (VBB) care and gather their recommendations for maintaining clinical proficiency.Design Exploratory qualitative study using semi-structured interviews and thematic analysis.Participants 10 hospital-based maternity care professionals (nine obstetricians and one clinical midwife), purposively sampled to represent experience and institutional diversity.Setting 10 hospital maternity units in a metropolitan region of the Netherlands.Key themes describing provider attitudes towards two proposed models of centralised care (mobile breech team, designated referral centre) and alternative strategies.Results Three core themes emerged: (1) proficiency—providers valued regular exposure, formal training and peer support, expressing concern that centralisation would reduce overall workforce readiness; (2) organisation—concerns included unequal access, staffing burden, legal risks and inefficiencies in mobile teams and (3) alternatives—participants preferred a regional breech network with shared training, joint video review and expert on-call support.Conclusions Maternity care providers opposed full centralisation of VBB, favouring a networked model that distributes expertise and preserves local access. These insights highlight the importance of involving frontline providers in service redesign.Trial registration number Not applicable.

Background: Transformative learning in health professions education aims to develop health professionals as "enlightened change agents", who critically question routines and contribute to health system improvement. In hospital governance contexts, dissent from professionals acting as enlightened change agents may be framed as nuisance. Objective: To explore how executive hospital board members interpret and respond to dissent from health professionals acting as enlightened change agents, and how they involve these professionals in governance and decision-making. Methods: We conducted a qualitative phenomenological interview study with six experienced hospital board members from academic and non-academic hospitals. Semi-structured interviews were thematically analyzed using an iterative inductive-deductive approach until data saturation was reached. Results: Board members portrayed themselves as translators of societal and technological trends into organizational policy who seek broad support while retaining final authority. They operated under ongoing financial and continuity pressures, which constrained room for innovative ideas that fell outside immediate priorities. Board members described dissent as welcome when it was perceived as constructive and actionable within current priorities. When dissent was perceived to delay decision-making or challenge strategic agendas, it was more likely to be reframed as "nuisance power". Three response pathways to dissent were identified: acceptance, tolerance and intervention. Interventions included appealing to majority rule, ignoring dissenters, using hierarchical authority, facilitating exit, or even involving external regulators. Conclusion: In this hospital governance context, change agency by professionals may be reframed as "nuisance power" when it is perceived to impede board priorities, highlighting how governance conditions shape whether dissent is engaged or marginalized. Implications: Hospital boards may reduce informal marginalization by explicitly organizing how dissent is heard and fed back within governance processes. Educational programs should better prepare future change agents to work strategically within governance processes through framing, alliance-building, and negotiation.

Background & Need for Innovation: Effective change management is critical to the success of organizational change initiatives. Failure rates are estimated at approximately 70%. Change projects in clinical education are embedded in complex environments, where patient care has priority, professionals traditionally enjoy a high degree of autonomy, and multiple stakeholders are involved. Achieving successful change in such settings requires careful preparation by leaders. External consultancy support is costly, while gaining a comprehensive overview of the change management literature is time-consuming. Goal of Innovation: A practical tool that prompts relevant questions tailored to clinical training settings. Steps taken for Development and Implementation of Innovation: The checklist was developed using a developmental evaluation approach. Over several years, we applied a question-based tool grounded in key concepts from the change management literature. Initially consisting of twelve questions, the tool was iteratively expanded based on user experiences, identifying themes most relevant to clinical training contexts. Multiple-choice response options were developed to prevent unproductive discussions. Outcomes of Innovation: The final product is a twenty-item checklist designed for discussion in small groups. Ideally, different stakeholder groups complete the checklist separately and subsequently compare perspectives on the change process. This approach facilitates a shared understanding of the risks of the change initiative and highlights unaddressed tasks. A game board, cards, and instructions are available for download and printing. Critical Reflection on Our Process: This change management tool offers a structured journey through selected change management concepts, supporting leaders in clinical training environments and stimulating dialogue about change processes in clinical contexts.

Background:Remote leadership has gained increasing recognition and become possible across sectors. Still, this approach is relatively new in the healthcare sector. The literature shows that the dynamic interaction among digitalization, remote working, leadership, and culture in the healthcare sector is under-researched. This review aimed to investigate how remote leadership is defined and conceptualized in healthcare organizations, how it is practiced across Western and non-Western cultures, and how these practices impact the healthcare sector. Methods:We conducted a scoping review and applied the JBI and PRISMA-ScR frameworks to guide it. Articles from PubMed, Scopus, and Web of Science were used as sources of literature. All studies were analyzed using descriptive and inductive thematic analysis. Results:Of 5310 studies, 17 met the inclusion and exclusion criteria. Our findings identified 4 themes: key concepts of remote leadership, competencies needed by remote leaders, opportunities and challenges of remote leadership, and how remote leadership is practiced in Western versus non-Western cultures. Remote leadership impacted on health system, organization, and service delivery. Lastly, we found that remote leadership in relation to culture was implicitly explored and is associated with leadership styles. Conclusion:This review indicates that conceptual clarity remains underdeveloped within the healthcare-specific literature. A notable finding was that cultural context remained underexplored, with culture frequently treated implicitly through leadership style rather than as a distinct analytical dimension of remote leadership in healthcare. Further research is needed to provide a comprehensive understanding that helps remote leaders manage remote work environments and enhance the sustainability of healthcare services in an evolving digital era.

Introduction: Personalization is increasingly emphasized in postgraduate medical education. While competency-based medical education (CBME) is theoretically positioned to support personalization, practical challenges such as fixed learning outcomes, workplace constraints, time-fixed rotations, and assessment requirements, often limit its realization. This case study aimed to explore how residents experience and make use of individualized development trajectories within a program that combined fixed outcomes with flexible program components. Method: We conducted a case study using semi-structured interviews and template analysis. The study was situated in the Dutch national Obstetrics and Gynecology residency program, which includes formally embedded individualized development trajectories with open-ended learning goals and no pre-determined assessment. We interviewed 12 residents and discussed their portfolios. Results: All participants engaged in individualized development trajectories. The level of engagement varied and motivation sprang from: personal interest, moral values and dilemma’s, clinical exposure, role models, and workplace possibilities. Three interacting factors enabled this: 1) formal program structure legitimized and fostered engagement; 2) time and workplace exposure allowed participants to recognize personally meaningful goals; 3) program directors’ support facilitated engagement. Program directors varied in their guidance: some coached, endorsed, or role-modeled; others merely monitored activity; and a few did neither. Participants engaged with the individualized development trajectories, despite the absence of assessment. Conclusion: Structured autonomy, workplace exposure and personal motivation can support personalized learning in CBME. Personalization requires intentional design, supportive structures, trust towards residents, and coaching attuned to the individual learner.

Introduction: Interprofessional Training Units (ITUs) on hospital wards offer a way to prepare healthcare students for collaborative care in the Landscape of Practice (LoP), where professional communities and patients intersect. While learning in ITUs aims to enhance teamwork and patient outcomes, little is known about patient perspectives on care and interprofessional education (IPE) in fast-paced ITU settings. This prompted our research question: What are patients' and their partners' perceptions of the care they received and of the educational dynamics in an ITU on a maternity ward? Methods: Using semi-structured interviews, we collected qualitative data from 14 pairs of patients and their partners in the ITU of a maternity ward in a Dutch teaching hospital between February and May 2025. We adopted an inductive constructivist thematic analysis, using sensitizing concepts from LoP and Core Competencies for Interprofessional Collaborative Practice to guide coding and interpretation. Results: We identified three interrelated themes concerning patients' and their partners' perceptions about care and education in the ITU: 1) Patients' need for trust in the student-team was the key condition for patients' acceptance of interprofessional care on the ITU. For patients to feel they could trust the student team, students needed to convey confidence while being transparent about their limitations and show genuine care for patients and their partners; 2) Patients' and partners' recognition of the value of IPE at multiple levels: for themselves, for the students, and for future patients; 3) Patients' and partners' view of their role in the ITU: when patients felt they were able to trust the student-team, and even more when they recognized the value of IPE, they expressed willingness to facilitate students' learning. However, they described this contribution as limited in scope: they were open to supporting IPE in practice as 'boundary spanners' but did not wish to take on a formal teaching role as 'boundary brokers.' Conclusion: Our study shows that learning with and from patients in an ITU requires shifting beyond a focus on students understanding each other's roles and responsibilities. Instead, it calls for an approach that also acknowledges the needs as well as desired roles of patients and their partners within the LoP. As 'boundary spanners,' patients and their partners can help bridge the gap between their lived experiences of care and students' different professional perspectives. We also offer some practical implications for ITU tutors.

Healthcare systems are increasingly complex, facing challenges such as rising costs, aging populations, and persistent health inequities. These challenges demand that medical education adapts, to equip health professionals with the competencies required to navigate and transform complex systems. This is where transformative learning theory can play a crucial role. This article offers twelve practical tips to integrate transformative learning in medical education, emphasizing the need for a shift from traditional educational approaches to more transformative methods. These tips focus on educating learners on the principles of transformative learning, encouraging critical reflection, fostering interdisciplinary collaboration, addressing the hidden curriculum, and creating a supportive learning environment. By implementing these tips, medical education can better prepare healthcare professionals to act as change agents, contributing to the long-term sustainability and effectiveness of healthcare systems. The potential impact of these tips on medical education is substantial, as they provide a pathway toward a more responsive, ethical, and sustainable future of healthcare. Clinical trial number: Not applicable.

Purpose This study aims to formulate a consensus on primary care physicians’ leadership competencies tailored to Indonesia’s rural and remote health systems using the LEADS framework. Effective physician leaders are essential in these settings; however, many physicians lack the necessary leadership qualifications due to insufficient training. From a medical education perspective, this issue is further compounded by the lack of consensus on leadership course content. Design/methodology/approach The study used a mixed-method approach with a concurrent triangulation strategy. Concurrently, a two-round Delphi study and qualitative interviews were conducted. The Delphi study involved academics, rural and remote primary care physicians, intern doctors (similar to house officers), clerks and medical students and used descriptive analysis. Semi-structured interviews, guided by an interview guide, were analysed using inductive thematic analysis. Findings From the initial 62 LEADS framework statements, the authors identified 52 physician leadership attributes in round 1 and 41 attributes in round 2. Qualitative interviews revealed three main themes: the significance of physician leadership, the physician leadership curriculum and its potential and impact. Originality/value The study established consensus and provided scholarly insights into the leadership development necessary for primary care physicians in rural and remote areas. This is essential for developing Indonesia’s medical leadership curriculum, with the ultimate goal of improving health outcomes in these settings.

CONTEXT:Increasing numbers of healthcare students are trained within interprofessional hospital placements, where they learn to be part of the landscape of healthcare practice. Explicitly facilitating (inter)professional identity development has been recommended as a goal of these placements. We aimed to explore students' experiences during their placement, and its relation to their learning and identity development. METHODS:In this multicenter qualitative study, nine medical students, six midwifery students, and six nursing students drew rich pictures of one satisfying and one challenging experience during their interprofessional placement, capturing complex, nonverbal elements of these experiences. We used semi-structured interviews to deepen understanding of students' experiences and their developing identities, adopting an inductive constructivist thematic analysis. RESULTS:During their interprofessional encounters, a range of emotions supported or challenged students' learning and identity development. These emotions played a pivotal role throughout the three themes we identified: (1) Understanding and appreciating differences; (2) Navigating identity tensions; and (3) Gaining confidence in patient-centered learning and collaboration. CONCLUSIONS:During interprofessional placements, most students engage in learning about each other's responsibilities and values, enhancing knowledgeability. Tutors should be aware of students' emotions during interprofessional encounters, and stimulate reflection on them, as emotions can foster or hamper students' knowledgeability and identity development.

ObjectivesOver the past few decades, knowledge of women’s health regarding sex and gender differences in health has increased but transfer of these new insights into medical education and clinical practice is lagging, resulting in substandard care for women compared with men. This study aimed to reach consensus on what all physicians taking care of women should know about women’s health.MethodsA Delphi study was executed involving statements prepared by experts in women’s health across 10 medical specialties and a patient advisory board. Participants were recruited from Europe and Northern America through the experts’ networks and snowball sampling. Participants voted IN/OUT on each statement based on its perceived relevance and feasibility for general physician knowledge, regardless of specialty. The statements were ranked according to a >80% consensus in the first Delphi round and a 4-point Likert scale in the second Delphi round.ResultsIn the first round, 44 participants fully completed the survey. 18 statements progressed to the second round, in which four additional statements were included based on participant suggestions. In the final round, 35 responses on the 22 selected statements resulted in consensus on 18 statements of the highest importance, within the following domains: the societal position of women in health, patient perception of disease and treatment, differences in symptomatology, pharmacological considerations and the impact of the female life cycle on health and disease.ConclusionConsensus was reached on the top priority clinical conditions and public health issues in women’s health, resulting in a list of 18 statements on women’s health that every physician caring for women should know, regardless of specialty. There was also consensus on the importance of incorporating these insights into medical education. The next step involves implementing women’s health education in medical schools, postgraduate education and continuing education for medical specialists.

AIM:To explore nurses' experiences with power structures in hospital care and to develop policy recommendations for transforming disempowering structures. DESIGN:A three-phased critical ethnographic design. METHOD:Data were collected in a general teaching hospital in the Netherlands between December 2022 and June 2024 through (1) ethnographic diaries kept by nurses, (2) semi-structured interviews, (3) partial participant observations, (4) one focus group discussion with only nurses and (5) one multistakeholder focus group. Thematic analysis was used to identify themes. FINDINGS:Twenty-eight nurses of thirteen different departments and nine stakeholders participated. Four themes emerged from the analysis: (1) power in cooperation, (2) hierarchical relationships, (3) aggression and (4) insufficient decision-making power in hospital policies. The first theme was experienced as an empowering structural condition, while the last three were identified as disempowering structures. CONCLUSION:Job satisfaction and quality of care among nurses are at risk and elicit feelings of burnout because of nurse-doctor hierarchies, aggression and insufficient decision-making power in hospital policies. Therefore, improving interprofessional cooperation and including nurses in decision-making is crucial to structurally empower nurses. IMPLICATIONS:Hospital administrators need to create empowering conditions for nurses by furthering inclusion in policy making and setting department goals, implementing interprofessional education for effective collaboration, increasing nurse representation throughout hospital management layers and ensuring strong support systems. These interventions are important in addressing aggression, hierarchies, nurse turnover and burnout. REPORTING METHOD:COREQ guidelines were used for reporting qualitative studies. PATIENT OR PUBLIC CONTRIBUTION:None.

Background While physicians are crucial to rural or remote healthcare systems, they are rarely trained as effective leaders, particularly in low-income and middle-income countries context. We conducted a 2-day workshop using the LEADS framework to assess whether rural or remote primary care physicians in Aceh, Indonesia, benefited from the leadership development programme and how their professional behaviour changed 6 months post-workshop.Methods We applied a mixed-methods study. 10 rural and remote primary care physicians who attended the 2-day workshop were interviewed using a self-reported questionnaire (Kirkpatrick level 3A). We also applied Kirkpatrick level 3B evaluation using qualitative reports from 10 of our workshop participants' colleagues and a quantitative survey from 50 colleagues in primary care, including superiors, peers and paramedics, with a 13-item questionnaire on a 5-point Likert scale. The interview transcriptions were analysed thematically, while the survey questionnaire results were analysed descriptively.Results After the workshop, participants self-reported improvements in three areas: (1) communication, (2) solving collaboration and (3) patient and community engagement. Through their colleagues' reports, participants improved in three areas: (1) communication, (2) leading figure and (3) inclusivity. Although the data suggested had benefits on the participants' professional behaviour needed in the workplace, further research is needed to support this.Conclusions Given the reported positive impact of the workshop on the participants' professional behaviour, leadership development programmes need to be an integral part of rural and remote healthcare delivery workforce development. Such programmes may be crucial for cultivating physician leaders who are adaptable to diverse contexts.

BACKGROUND:The relation between maternal mental health and breastfeeding is complex, with breastfeeding often associated with improved well-being. OBJECTIVE:This study investigates associations between breastfeeding outcomes and psychological well-being in women with traumatic birth experience (TBE). METHODS:This exploratory secondary analysis utilized data from the PERCEIVE randomized controlled trial, which assessed the effectiveness of early eye movement desensitization and reprocessing (EMDR) therapy on posttraumatic stress disorder (PTSD) symptoms after TBE. Women with self-reported TBE (n = 143) were recruited between 2020 and 2023 from a hospital and midwifery practices in the Netherlands. Breastfeeding status was assessed at two (T0) and nine (T1) weeks postpartum. Outcomes were assessed using validated questionnaires on mother‒infant bonding (PBQ), PTSD symptoms (PCL-5), depression (EPDS), fear of childbirth (W-DEQ-B), and quality of life (WHOQOL-BREF). RESULTS:Among 143 participants, 126 initiated breastfeeding. At T0, breastfeeding women reported fewer symptoms of mother‒infant bonding difficulties, compared with non-breastfeeding women, p = 0.004. At T1, descriptive analyses found that participants who stopped breastfeeding reported more PTSD and depression symptoms. CONCLUSIONS:Our findings suggest that breastfeeding enhances mother-infant bonding after TBE. The weaker bonding reported in nonbreastfeeding participants, coupled with possible poorer mental health outcomes, underscores the need for targeted interventions to support breastfeeding and bonding in this population.

Purpose : To assess whether adding 5 minutes of slower, nutritive suction cycles to a standard 15-minute breast pump initiation program increases expressed milk volume during the first 4 days postpartum. Background : Early and effective colostrum removal is critical for breastfeeding success and neonatal health. Standard initiation suction patterns are primarily non-nutritive and may be suboptimal for colostrum extraction. Methods : This prospective pilot study was conducted at OLVG hospital in the Netherlands. Breastfeeding patients (n = 40) who gave birth after 36 weeks gestation with an infant aged ≤96-hour old and a clinical indication to express milk with a breast pump were recruited. Patients participated in one single 20-minute breast expression session using a hospital-grade electric breast pump with a 15 minute predominantly non-nutritive standard suction pattern followed by 5 minutes with a nutritive suction pattern. The primary outcome was the difference in the total expression volume after 20 min compared to 15 min of expression. Secondary outcomes were differences in expression volume by postpartum day, parity, mode of birth, and prior experience breastfeeding. Results : The study found that the primary outcome total colostrum/milk expression volume after 20 minutes was significantly improved compared to 15 minutes of pumping (4.69 ml vs 7.6 ml, P < .001). With the additional 5 minutes yielding 36% of the total milk yield. Conclusions : This study suggests an improvement in milk expression volume driven by the implementation of 5 minutes of additional of nutritive breast pump suction cycles. Implications for practice and research : This pilot study contributes to novel insights into milk removal dynamics in the first days after birth. Trial registration : Registered on clinical trials.gov NCT04619212. Date of registration: November 6, 2020.

This case-based qualitative study explored the professional identity as experienced by health professionals working in an integrated maternal-neonatal ward when their practice changed from a "paternalistic" model, in which physicians and nurses were in charge, to a shared or "consumerist" model, to increase parent autonomy. We analyzed transcripts of focus group discussions and interviews with 60 health professionals on their experiences with empowering parents and described factors associated with themes of professional identity. The changes most affecting professional identity were the constant proximity of parents to their newborns and the single-family room design. These changes influenced three themes of professional identity: (1) connectedness and relationships (2) communication, and (3) competencies. A fourth theme, values, beliefs, and ethics, affected how the health professionals coped with the changes in the first three themes. When empowering parents of newborns in a hospital setting, health professionals experience beneficial as well as threatening shifts in their professional identities. Values, beliefs, and ethics associated with family integrated care helped health professionals to embrace their new roles, but other values, beliefs and ethics could create barriers. Continuous professional identity development in a patient-inclusive team is a topic for future research.

Background Globally, rural/remote health systems fall short of optimal performance. Lack of infrastructure, resources, health professionals and cultural barriers affect the leadership in these settings. Given those challenges, doctors serving disadvantaged communities must develop their leadership skills. While high-income countries already had learning programmes for rural/remote areas, low-income and middle-income countries (LMICs), such as Indonesia, are lagging behind. Through the lens of the LEADS framework, we examined the skills doctors perceived as most essential to support their performance in rural/remote areas. Methods We conducted a quantitative study, including descriptive statistics. Participants were 255 rural/remote primary care doctors. Results We discovered that communicating effectively, building trust, facilitating collaboration, making connections and creating coalitions among diverse groups were most essential in rural/remote communities. When rural/remote primary care doctors serve in such cultures, may need to prioritise harmony within the community and social order values. Conclusions We noted that there is a need for culture-based leadership training in rural or remote settings of Indonesia as LMIC. In our view, if future doctors receive proper leadership training that focuses on being competent rural physicians, they will be better prepared and equipped with the skills that rural practice in a specific culture requires.

ObjectivesMany studies on educational interventions to enhance residents' shared decision-making (SDM) skills show limited improvement in SDM skills and clinical outcomes. One plausible explanation for these suboptimal results is the insufficient emphasis on the educational quality of training interventions.MethodsThis review evaluates interventions' educational quality using an evaluation framework based on a previous study on effective skills transfer and a well-known SDM model. A systematic review was conducted, searching three databases until December 13, 2022. We assessed study quality by calculating MERSQI scores, examined the levels of study effects based on Kirkpatrick's model, and applied our evaluation framework to assess the interventions’ educational quality. Given the heterogeneity among the studies, a meta-analysis was not feasible.ResultsTwenty-six studies were included. Role-play and feedback were common training characteristics (65% and 54% of interventions). Only four studies (15%) met our framework's high educational quality threshold. No correlation was found between MERSQI scores and educational quality.ConclusionsThis review is a valuable attempt to assess the educational quality of SDM interventions beyond measuring study outcomes.Practice implicationsFuture evaluation frameworks should consider study results, training characteristics, and training content. Our framework offers a sound basis for such an evaluation framework.