Aspects of Nursing Education: The Types Of Skills And Knowledge Required To Meet The Changing Needs Of The Labour Force Involved In Nursing - Literature Review
Midwifery Care
The themes that emerge from the midwifery literature are similar in nature to those that have emerged from the literature in general. The literature acknowledges that nurses' work within multi-disciplinary teams and research investigates outcomes relating to nurses adopting expanded roles and coordinating and leading obstetric care.
Traditional models of providing obstetric care involve the participation of multiple caregivers. In the United Kingdom and Australia there is a high level of evidence supporting a 'continuity of care' model. In this model care is coordinated throughout the antepartum, intrapartum and postpartum experience (Hundley, Milne, Glazener & Mollison, 1997 UK; Sandall, 1997 UK; Hodnett, 1999 UK/AUS; Biro, Waldenstrom & Pannifex, 2000 AUS; Waldenstrom, Brown, McLachan, Forster & Brennecke, 2000 AUS; Spurgeon, Hicks & Barwell, 2001 UK) by a single caregiver or groups of caregivers working together. The continuity of care model is examined both as a stand-alone theme and in the context of the implementation of primary care models. Research also supports the midwife in a lead role in continuity of care models.
One Cochrane systematic review (NHMRC level I) conducted by Hodnett in 1999 (AUS) searched for randomised control trials to assess continuity of care from pregnancy through the postnatal period compared to usual care by multiple care givers. Two trials (Flint, 1989 UK and Rowley, 1995 AUS) were identified to be of good quality, although it was unclear whether randomization was centrally controlled. Both trials compared continuity of care by midwives with non-continuity of care by a combination of midwives and physicians. A total of 1815 women were included with the key findings being that women who had continuity of care were less likely to be admitted to hospital antenatally and were more likely to attend antenatal education programs. These women were also less likely to have drugs for pain relief in labor, less likely to have an episiotomy, but more likely to have a vaginal or perineal tear. Their newborns were less likely to require resuscitation, but there were no differences in Apgar scores, birthweight parameters and stillbirth or neonatal death rates.
Three recent good quality studies (NHMRC level II evidence) reported similar findings. Homer, Davis & Brodie (2000 AUS) sampled 1089 women (550 in the experimental group and 539 in the control group) using a questionnaire. 775 women responded and those in the group who received coordinated care from a team of midwives reported greater satisfaction with their care compared to the control group who received traditional physician led care. In particular they reported shorter waiting times at appointments, found the clinics/venues more accessible, didn't feel as rushed and developed an easier rapport with the midwives.
Two Australian studies also examined the differences between team midwifery and traditional multiple caregiver services in two large public hospitals in Melbourne, Victoria. Biro, Waldenstrom & Pannifex (2000 AUS) extracted data on interventions and maternal and infant outcomes from hospital records of 502 women assigned to team midwifery care and 498 women assigned to standard care (n=1000). The continuity in midwifery care model was associated with a reduction in medical procedures in labor and a shorter length of stay without compromising maternal or perinatal care. Waldenstrom, Brown, McLachan, Forster & Brennecke (2000 AUS) used a postal questionnaire to elicit data from 1000 women, 495 who were randomly allocated to team midwifery care and 505 to standard consultant led care (n=1000). Interestingly, the results from this study differed in that there was no difference between the intervention and control group with regard to medical interventions. However, similar findings were noted regarding increased satisfaction with midwifery team care. In particular this research supported the findings of Homer et al with the greatest difference in satisfaction relating to the antenatal period.
Two further studies provide additional evidence at the NHMRC level III-1. Spurgeon, Hicks and Barwell (2001 UK) conducted a randomised controlled trial researching a community-based continuity of care model. Two pilot groups of 112 and 103 women were randomly drawn from GP practices in the catchment area of Central England. The first group was allocated to one-to-one midwifery care and the second group evolved naturally to the care provided by a small group of midwives. A third group of 118 women were drawn from the Trust's obstetric unit to act as the control group. A questionnaire was administered six weeks postnatally and found that patient satisfaction was highest in the midwifery care groups, information and advice received from the midwifery groups was rated more highly and the women in the intervention groups felt that the midwives acted as partners in decision making.
In an earlier study, Hundley, Milne, Glazener & Mollison (1997 UK) results were not so conclusive. These researchers allocated 2844 women to either a midwife unit (continuity of care model) or a labor ward (traditional model). A 2:1 randomization method in favor of the midwives unit was used to take into account transfer rates. Hundley et al used a questionnaire to evaluate the outcome measures of satisfaction, continuity of carer, choice and control. While the responses revealed that overall experiences did not vary significantly, the midwives group was significantly more likely to have made their own decisions regarding pain relief.
It is evident from the above literature that midwives at all levels within the profession are involved in changing service provision that aims to increase continuity of care and carer for the woman. Within maternity services this has often been interpreted as women-centred care with the need for the woman (and her partner, if she wishes) being the focus of care (Pope, Graham & Patel, 2001 UK). A research project by Pope, Graham and Patel (2001 UK) was commissioned by the English National Board for Nursing, Midwifery and Health Visiting. The aim of the study was threefold. Firstly, it aimed to establish the current role and responsibilities of midwives in a variety of settings with a range of client groups. The second aim was to identify the changing educational needs of midwives to fulfil their future widened role and responsibilities within the changing maternity services. The final aim was to provide information from which to develop an educational package to assist midwives to respond to the requirements of their changing role and responsibilities. Both quantitative and qualitative methodologies were employed and included a national survey of midwives, midwifery supervisors and doctors. The study indicated a strong commitment to women-centred care on the part of midwives. Similar to the findings by Waldestrom et al (2000 AUS) and Homer et al (2000 AUS) this was best translated into practice in the antenatal setting. The picture of hospital care that emerged was less organised. Accordingly, the researchers recommend that the introduction of more structured frameworks for care would reduce individual variability in care and afford better monitoring for quality assurance purposes. Continuing education needs for midwives were identified to include expanded clinical skills such as intravenous cannulation, perineal suturing, ultrasonography, labor and delivery in water, and interpretation of cardiotocography. There was also an emphasis on educational preparation regarding research skills, communication, counselling skills and general issues relating to professional practice such as ethico-legal considerations and accountability.
A central theme from all of the studies is that the introduction of a continuity of care model has significant implications for future planning and provision of antenatal, intrapartum and postnatal services. While it is unclear whether the results from the studies provide a high level of evidence to support continuity of care or midwife led care it is clear that there exists a potential role for the midwife to be the primary carer in both community and hospital based obstetric care. Furthermore, the introduction of this model of care creates the potential for expansion of the midwife's role to include greater control and autonomy in practice. These latter attributes are particularly important as the multi-centre case study (NHMRC level IV) by Sandall (1997 UK) reveals that continuity of carer is not only a key issue related to satisfaction for childbearing women, but that it provides three key components that can prevent 'burnout' relating to midwifery work. These components include affording midwifes the opportunity for achieving occupational autonomy, receiving intraprofessional support and the possibility of developing meaningful professional relationships with women.
As detailed earlier in the review, the establishment of GP led Primary Care Groups (PCG's) to supply primary care to local communities has been a major new initiative designed to assist modernisation of the United Kingdom's National Health Service (NHS). The narrative paper by Houston (2000 UK) reports on how this change in service has impacted on the role of midwives. According to Houston, midwives in the UK deliver the majority of care to childbearing women at all stages of the childbearing episode. With the implementation of the GP led Primary Care model of service delivery they are required to become actively involved in PCG's, contributing to local health improvement programs and working in partnerships with other professionals delivering primary care services.
In the past such multi-disciplinary teamwork has not always occurred as demonstrated by studies by Mbwili-Muleya, Gunn & Jenkins (2000 AUS), Pope et al (2001 UK) and Fenwick, Morgan, McKenzie and Wolfe (1998 UK). The Australian study by Mbwili-Muleya et al reveals difficulties relating to professional liaison between Maternal and child health nurses during the postnatal period. This qualitative study used a postal survey to sample 1104 GP's in Victoria. The sample included all listed female GP's (n=503) and a random selection of male GP's (n=601) to allow for the effects of gender. Of the 775 GP's who responded, half had no contact with maternal and child health nurses in the previous month, with 56% of contacts being initiated by maternal and child health nurses. The researchers recommended that further study was required to identify the benefits of increased maternal and child health nurse and GP contact on maternal and infant outcomes. In the meantime however, they suggest that a more systematic approach to the contact between these two providers of postnatal services would lead to a better coordinated, more cost-effective and efficient use of services.
The case study component of the research by Pope et al (2001) identified that midwife and GP partnerships are placed under particular tension when a woman requests a home birth. The qualitative study by Davies, Hey, Reid and Young (1996 UK) identified that midwives experienced a lack of support from GP's who were not keen to be involved or present at home confinements. Pope et al report that this leads to the breakdown of established GP/midwife partnerships as the midwife would assist a woman to look for another GP if the woman met the criteria for a home birth but her own GP prevented her from taking up this option. Fenwick, N., Morgan, M., McKenzie, C., & Wolfe, (1998 UK) also identified reluctance on the part of GP's to fully commit to partnerships with midwives. In this study postal questionnaires were sent to 58 GPs referring women to midwifery group practices, a shorter questionnaire was sent to the remaining 67 GPs (non practice group) in the same postal area. In depth interviews were conducted with 12 GPs. The researchers found that despite 80% of group practice GPs believing that midwives had the skills to detect deviation from normal, they did not wholeheartedly embrace working in partnership. While 66% of group practice GPs would confidently refer women to midwifery care, 50% of group practice GPs felt that midwives discouraged women from visiting GP's. As a result, 33% of group practice GPs felt they were seeing group practice women too few times for antenatal checks. It appears that poor communication was essentially to blame with 64% of group practice GP's identifying that communication with group practice midwives was poor.
Accordingly, Houston recommends that midwives develop improved leadership, communication and negotiation skills in addition to enhancing their practice skills. Drawing attention to the Department of Health document "Making a Difference" (1999 UK) that calls for midwives to expand their role to include wider responsibilities for women's health, Houston and McFarland (1999 UK) identify a number of areas in which midwives practice skills can expand. These include further development of knowledge and skills related to midwifery, women's health, public health, fertility, health promotion and screening. It is envisaged that primary care, acute care leaders and universities will work together to develop new educational programs. These programs will aim to address these needs to ensure that midwives will contribute effectively to the provision of good quality, cost-effective care that meets the needs of local communities.
An example of an educational program with such a focus is reported in the literature. The paper by Brittain (1999 UK) provides an account of a course developed by the Department of Midwifery Studies at the University of Central Lancashire (UCLAN) in response to a request from the North West Regional Health Authority. UCLAN developed a 3-day program to provide family planning nurses with specific skills and knowledge to provide emergency hormonal contraception using a protocol in the absence of a doctor. Brittain explains that this extension of the family planning nurse role is a particularly significant for public health as one third of live births in the United Kingdom are unintended. The aim of the educational program was to increase the availability and accessibility of emergency hormonal contraception in the North West Region while at the same time providing a clear framework for safe practice.
The need for providing adequate education and the necessary safeguards when expanding the current role of nurses is also highlighted by a qualitative study by Jowett, Peters, Reynolds and Wilson-Barnett (2001 UK). This study was commissioned as a part of the larger study by the English National Board for Nursing, Midwifery and Health Visiting and consisted of a questionnaire examining three main areas. Firstly, the researchers asked respondents about their awareness of the Scope of Professional Practice for nurses, midwives and health visitors document that encourages expanded roles for these professionals. Secondly they asked whether there were any activities/practices that the respondent would like these professionals to do that were not currently part of their role. Thirdly, they asked whether the respondent had any concerns about these professionals expanding what they do. The questionnaire was distributed to medical organizations, professional bodies, consumer groups, government departments, health authorities, social service departments, community health councils, private health care providers and centres for nursing and midwifery education. 212 responses were received. Responses revealed that there was a high degree of awareness about the Scope document (85%), 25% of respondents described prescribing as a desirable component of expanded practice, 40% were concerned that staff required adequate training and 23% identified the need to safeguard patients.
While the literature reviewed so far has focussed on midwifery practice in the UK and Australia, the literature emanating from the United states identifies similar issues relating to the impact of health care system developments on midwifery and the roles that midwives play in women's health care. A narrative paper by Paine, Dower and O'Neil (1999 USA) reports the recommendations of a Taskforce on Midwifery convened in 1998 by the University of California at San Francisco Center for the Health Professions. The Taskforce of eight experts from across the country explored the effects of market-driven changes on midwifery and made fourteen recommendations related to midwifery practice, regulation, education, research and policy. The recommendations include permitting midwifery care access to all women requesting that care by ensuring that midwives are placed in a variety of health care settings. They also recommend that when making decisions about access to midwifery services policy-makers, regulators, hospitals and health-plan administrators avail themselves of the research data suggesting that women experience a high level of satisfaction with midwifery care. In times of economic reform the panel of experts recommended that improved education, expansion of the midwifery role and integration of midwifery services would result in provision of high quality care at a reduced cost. Recommendations for educational programs included providing opportunities for intra-professional education and training experiences and allowing for multiple entry points. Recommended curricula components include evidence-based health care, cultural competence, information management, population-based skills (epidemiology, biostatistics, behavioural and political sciences) and health care policy and financing. Policy recommendations include the recognition of midwives as independent and collaborative practitioners with rights and responsibilities relating to scope of practice. Finally, in order to implement the preferred model of professional practice, the panel recommended that laws relating to entry to practice standards be passed by State legislatures.
Although conducted two years prior to the paper by Paine, Dower, & O'Neil, (1999 USA) was published, a national postal survey of 600 midwives (Kraus, 1997 USA) revealed that the scope of practice of the nurse-midwife has increased over recent years. The questionnaire was mailed on an nth name basis to members of the American College of Nurse Midwives (ACNM). Responses revealed that the typical American midwife either practices in a hospital (27%) or in a physician's practice (24%). The midwives surveyed provide total patient care for an average of 140 client's per month, chiefly delivering care to childbearing women. While pregnancy related practice was unchanged from a similar survey in 1993, role expansion has occurred in the area of well-women gynecology, nutrition, mental wellness, primary care and post-menopausal care. The greatest change identified was the rise from 51% to 84% of midwives reporting prescribing autonomy and authority.
The literature reviewed did not reveal high-level evidence regarding outcomes relating to the expanded practice roles referred to by Paine et al (1999 USA) and Kraus (1997 USA). One study of a high level of evidence (NHMRC III-2) was conducted by Davidson (1999 USA) for a PhD dissertation. Davidson employed a descriptive one-group design to explore the outcomes of nurse-midwifery care for high-risk mothers reported positive outcomes. This longitudinal study included a sample of 803 women with one or more high risk factors who were cared for by nurse midwives over a ten-year period. The researcher found that the high risk women in nurse-midwifery care enjoyed a lower cesarean section rates than national averages, experienced higher rates of vaginal delivery and vaginal delivery after cesarean section, and their newborns were less frequently admitted to neonatal intensive care than the national statistics report. Findings both support the midwifery led primary care model and suggest that nurse-midwifery care may help to reduce medical expenditures.
A case study (NHMRC level IV) by Corrarino, Williams, Campbell, Amrhein, LoPiano & Kalachik (2000 USA) used a non-experimental design to evaluate the outcomes of public health nurse visiting to another high risk group of pregnant women. Although this study does not directly relate to midwifery care, it does describe nursing interventions relating to a women-centred care model. The aim of the very limited pilot study was to assist pregnant substance abusers to enter drug treatment. All ten substances abusing pregnant women had full-term infants, their substance abusing behaviour improved and 80% retained custody of the child. While this study suggests that nurses can usefully employ strategies to assist substance-abusing women enter drug treatment, further studies are needed to assess the assistance and care most likely to result in improved models of care for substance abusing pregnant women.
A paper by Ecenroad & Zwelling (2000 USA) reported findings from a patient satisfaction survey following the transition from a traditional maternity unit to a family centred care model. The change in service was from an 'illness' model to 'wellness' model with care based on evidence rather than ritual and tradition. The introduction of this model involved significant staff education. A total of 259 women were surveyed with 96% finding their family-centred birth experience to be positive.
The remainder of the literature retrieved from American authors relates to evaluation of different models of midwifery service delivery in terms of providing quality care at a reduced cost. A qualitative study by Higgins (1996 USA) as part of a PhD dissertation reviewed 67 private nurse midwifery practices to assess their relatively profitability and organisational adaptation to environmental change. She found that only 20 reported successful business performance relative to the industrial standard and this was not related to organisational adaptation. The remaining articles fall into the category of expert opinion. For example, Ernst (1996 USA) argues that in collaboration with physicians, midwifery care and birth centres are well placed to provide quality economically sustainable services to as many as 85% of childbearing women. In the model presented, nurse-midwifery care focuses upon wellness. In addition midwives can identify deviations from normal and implement life-saving interventions through mutually agreed upon protocols. Pence (1997 USA) reported a shift from total patient care to delegated, shared accountability in a birth centre. Essentially this is a model of patient focussed care where new parents and their neonates receive care from cross-trained workers. Its implementation was driven by the managed care agenda and the author claims that it can be effectively applied to respond to increasing economic pressures.
The final two American articles reviewed relate to advanced practice roles in midwifery and maternal/child nursing care. Menihan (2000 USA) discusses the use of limited ultrasound in nursing practice and the issues surrounding this new skill incorporated in midwifery practice. This extension of perinatal services provides the potential for midwives to gain information relating to fetal wellbeing to complement the assessment of the fetal heart. Implications for practice include the necessity for accreditation, as nurses performing this investigation will be accountable for the quality and accuracy of the reports. The author reports that the Association of Women's Health, Obstetric & Neonatal Nurses recommends nurses wishing to enhance their role with this new skill undertake an educational program to gain an understanding of the theoretical and clinical guidelines for limited sonography.
A narrative paper by Lewis (2000 USA) describes the changes and dramatic growth of maternal and child health nursing in the past 25 years and the development and importance of advanced practice nursing. Lewis paints the picture of a healthcare environment characterised by severe nursing shortages, an aging nursing workforce, in which nurses are increasingly expected to prove their cost-effectiveness and unique contribution to the health care system. Despite this rather grim picture, Lewis maintains that there are many new and exciting opportunities for nurses to be employed in advanced practice roles. Such opportunities arise in the areas where technological advances lead to expansion of the nursing role. For example increased complexity of care precipitated by the genetics revolution and reproductive technologies and in the childbearing and paediatric populations where the numbers of infants and children with complex health care needs have increased. Finally, Lewis advises that nurses need to remain strongly connected to their nursing identity while at the same time collaborating rather than competing with other health professionals.
Any comments or queries should be sent to: highered@dest.gov.au
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