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education links National Review of Nursing EducationMidwifery EducationLiterature Review and Additional Material (Revised Edition)2. Methodology2.1 Levels of EvidenceThe utility of a ‘levels of evidence’ approach to assessing the quality of literature presumes ‘objectivity’ that is only possible in the presence of high quality empirical data. The ‘levels’ of evidence available to use in a review such as this are limited. As in health care itself, there are many areas ‘where sufficient research based evidence may never exist. In such situations the development of guidelines will inevitably be based partly or largely on the opinions and experience of … [those] with knowledge of the subject at issue’ (Black et al 2001). A modified version of methods suggested to build high quality consensus, as described in this recent text, has been in process in Australia over some years. A group of educators from all states and territories, led by the ACMI, have been working to develop educational standards for a BMid. Their publications, based on consensus building deliberations, have informed relevant conclusions drawn in this Review. The researchers in the AMAP team who contributed to this review have also worked in a similar fashion, that is, they have worked as a group rather than accepting that one ‘best person’ has sufficient knowledge or is free from personal or professional idiosyncrasy. Findings from empirical data have been generated by AMAP and are integrated with our own different opinions, backgrounds and experiences. This process has been described as ‘synthesising judgement’; a necessary step in making high quality decisions in the absence of certainty (Black et al 2001). The AMAP researchers include midwives who have practised in three closely professionally-linked countries (Australia, the United Kingdom and New Zealand) and who have been involved in leadership in education, practice development and improvement for over 25 years. The constant between the researchers is their recognition as ‘expert’ by the professional community in a number of countries, by bodies such as the World Health Organisation, national and state governments, and international midwifery associations. This Review therefore builds and relies heavily on consensus development derived from expert opinion and synthesised with empirically derived data when this exists. 2.2 Literature Search StrategyThe researchers, together with a panel of international experts who assisted, identified a list of ‘keywords and synonyms’, which were used to search relevant databases:
A systematic review of the literature between 1985-2001 was conducted using the Ovid databases (Medline 1966 to July 2001, Cinahl 1983 to June 2001) and the MIDIRS Midwifery Digest. MIDIRS Midwifery Digest1 provides maternity health professionals with an overview of key international midwifery and medical research to inform their practice. The research is gathered from over 550 international journals. In addition, articles are commissioned by MIDIRS on the issues currently being discussed by the midwifery profession and these have also been drawn on. This literature would not have been found by conventional search methodology. Papers gained from these searches were examined to identify new literature sources both published and unpublished. In addition, focussed searches were conducted using the names of authors known to have published on the topic. Policy and other non-refereed documents have also been drawn on. 2.3 Literature AnalysisThe literature was categorised by type (e.g. policy document, expert opinion, research based). Where relevant or possible, the quality of the literature was graded according to type of research and quality of research. Much of the literature on midwifery education is found in policy and professional opinion literature, as relatively few rigorous studies and no randomised trials have been conducted either internationally or in Australia on the effectiveness of various forms of educational programs used to prepare midwives. Three Australian research studies are worthy of note, according to conventional classification systems. Lesley Barclay’s 1986 Masters Thesis investigated the quality of hospital based midwifery education across Australia based on the experience of new graduates, using a survey modified from a large United Kingdom study. The results of this were published nationally and internationally. In 1992, Heather Hancock published the results of a study that researched all ten midwifery programs that had, at that time, moved to higher education institutions throughout Australia. Most recently and pertinently to this Review, the Australian Research Council funded AMAP study has surveyed all of the Australian pre-registration midwifery courses for nurses who wish to gain a qualification for initial authorisation to practise midwifery. This study has compared courses on a range of issues such as course demographics, prerequisites, minimum theoretical and clinical hours of education, clinical supervision and teaching processes. The results of this survey can be found within this review of midwifery education. An extensive, focussed, literature search on midwifery education in the UK, Canada, New Zealand, Netherlands and the USA (drawing in particular on MIDIRS searches specific to these countries) has been made. The researchers’ private collections of relevant documentation, much of which has been gathered during educational visits to these countries, also informed the initial search. Midwifery education experts from each country were identified through already established networks, several of them having already provided information and advice to the ACMI Bachelor of Midwifery National Taskforce. These international experts were informed of the purposes of this Review, and were invited to comment on an initial draft of an overview of midwifery education and development in their country written by Nicky Leap. They were asked to confirm that key issues relating to midwifery development and education in their country were adequately and accurately addressed and to inform the researchers of any sources of unpublished literature or literature that had not been accessed in the initial search. The international experts were asked to address the themes identified for this Review, in particular issues relating to standards for midwifery education and the development of these in each of their countries. A two-way process of editing, revising and re-writing drafts of each document relating to individual countries took place electronically. This process continued until such time as the experts were prepared to 'sign off' on a final draft that they believed to be an accurate reflection of midwifery education in their country.2 The Australian researchers were confident therefore that questions relating to potentially comparable issues had been addressed, though a limitation might be that bias originating from the authors who may be invested in the current situation remains.3 2.4 The Contribution of the Australian Midwifery Action Project to this Inquiry2.4.1 Education SurveyA preliminary analysis of the AMAP surveys on pre-registration midwifery education contributed to this Review and the findings are presented in Section 4 of this Review. The study into Midwifery Education, Mapping Midwifery Education in Australia, was undertaken by the Centre for Family Health and Midwifery as part of the AMAP Project. The aim of the study was to describe the current position of midwifery education across Australia. Using a structured questionnaire (Appendix B) undertaken primarily by telephone interview, a survey was carried out of universities offering a midwifery course leading to authorisation to practise as a midwife. Ethics approval was given for the study in October 2000. The study commenced in May 2001 and data collection was completed in August 2001. To identify which universities conducted midwifery programs, the AVCC web page listing all universities in Australia was accessed. From here the researcher identified which universities had midwifery programs. Following this, 30 universities were telephoned to confirm that the university had a midwifery program that led to authorisation to practise as a midwife, as well as to identify the course coordinators and gain contact details. Ultimately, a total of 27 universities were found to be offering midwifery courses leading to authorisation to practice. The final sample included the midwifery course coordinators from all 27 eligible universities. The data was analysed to:
2.4.2 Practitioner SurveyAMAP has surveyed practising midwives through the midwifery and nursing press, a web based survey, and participant responses at midwifery conferences in rural and urban settings across Australia. There are 258 Study Tour questionnaires, 390 Journal questionnaires and 40 Website questionnaires completed. In addition, Graffiti sheets have been collected at eight venues across Australia. Participants through all of these sources were asked to comment on what they see as the barriers affecting Australian midwifery and potential strategies to address these barriers. This data is in the process of being analysed with the aid of a computerised software program. The researcher leading this section of the AMAP study, (Pat Brodie) was asked to identify issues relating to midwifery education from the preliminary analysis. This data informed the Review in relation to Australian midwives’ views of midwifery education, albeit in a limited fashion given time constraints and the stage of analysis of the data. A short series of quotes extracted from this data has been included later in this Review. 2.5 An Analysis of the Development of the Australian Bachelor of Midwifery in Australia and National Educational StandardsAMAP has also observed and reported on the development of national standards for the accreditation of Bachelor of Midwifery programs. This process has been undertaken by midwifery education experts from each state and territory so we are confident of the quality of census building that has occurred (Black et al 2001). Publications and information packages relating to the process of the development of the proposed Australian Bachelor of Midwifery were accessed by the reviewers from the ACMI National Bachelor of Midwifery Taskforce. These documents, supplied with full support and permission, were used to describe:
2.6 An Analysis of the Continuing Education Needs of Australian MidwivesInformation related to new midwifery models of care that are being developed in Australia has recently been compiled and developed into a resource published by the CFHM (Homer, C.; Brodie, P. & Leap, N. 2001. Establishing Models of Continuity of Midwifery Care in Australia). A search regarding these new models and education programs to prepare midwives to work in new roles was carried out as part of developing this resource by accessing databases, conference proceedings, university web sites and various informal networks including the ‘ozmidwifery e-mail chat line’. This data is not directly presented here but has been integrated in the Review. 2.7 Re-entry ProgramsAn attempt was made to collect sound data on the numbers of midwives who completed some of the larger, state government sponsored, midwifery re-entry programs. We are not satisfied with the quality of the data we have been able to access and will continue to try to produce more useful data to supply to the National Review of Nursing Education. Foot Notes: 1.Quarterly Journal of the Midwives Information and Resource Service 2.The USA review remains subject to further review as at March 2002 but work to date has been included. 3.The international experts were invited to write a short personal profile to attach to their contribution. These are included in the relevant sections and demonstrate the quality and experience they brought as consultants to this Review. |
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