Theory building in nurse-midwifery. The care process

A theory of the aims and objectives of midwifery practice: A theory synthesis

INTRODUCTION

Every discipline has a dichotomous objective by which it recognizes whether its work has been successful (Vogd, 2011). For midwifery care, no objective has been set in this way so far. This also has implications for measuring quality, because quality of care is only measurable if objectives have been identified. This paper aims to contribute to theory formation in midwifery science by analysing existing concepts and theories and preferences of women to midwifery care to answer the question of the dichotomous objective of midwifery.

METHOD AND FINDINGS

The method of theory synthesis (Walker and Avant, 2011) was used to analyse existing theories and concepts of midwifery care and literature-based preferences of women to midwifery care and synthesize them with regard to the objectives of midwifery care. The synthesis took place in the form of a means-end chain to extract the dichotomous target of midwifery care. In this way, the objectives of midwifery could be compared and linked from both the scientific and from women's perspective. The resulting means-end chain model of the process of midwifery describes the aims and objectives of midwifery from the point of view of women on three levels.

DISCUSSION

The hierarchical model of the process of midwifery presented here is a first attempt to illustrate the aims and objectives of midwifery practice in a means-end chain model in order to facilitate discussion on the topic and to make the quality of midwifery care measurable. Measurement is a first step towards improving quality of midwifery care and thereby improving women's reproductive capabilities.

Development of middle-range theories in nursing

ABSTRACT Objective: To identify in the literature how Middle-Range Theories (MRT) are being developed in Nursing. Method: Integrative review on the databases Lilacs (Latin American and Caribbean Literature in Health Sciences), Scopus, Cinahl (Cumulative Index to Nursing and Allied Health Literature), Web of Science and PubMed portal, using the keywords middle range theory and nursing, as well its Portuguese correspondents (Lilacs), and the Boolean operator AND. The sample included 25 articles. Results: All articles presented concepts related to MRT. Most developed a synthesis picture. Some theories have formulated specific propositions, hypotheses, and names. Only 16 articles cited the methodological framework, while 22 used theories or models for theoretical foundation and 11 carried out literature reviews. Final considerations: The development of MRT included the presentation of fundamental concepts, synthesis, propositions, hypotheses and specific name. The MRT is recognized as a way of developing knowledge to guide the nursing practice.

Health professionals' perceptions of a midwifery model of woman-centred care implemented on a hospital labour ward

BACKGROUND

Theoretical models as a basis for midwives' care have been developed over recent decades. Although there are similarities between these models, their usefulness in practice needs to be researched in specific cultural contexts.

AIM

To explore whether, when adopted by midwives on labour wards, a midwifery model of woman-centred care (MiMo) was useful in practice from the viewpoint of a variety of health professionals.

METHODS

Data were collected from a variety of health professionals before and after an intervention of implementating MiMo at a hospital-based labour ward in Sweden, using nine focus group interviews with a total of 43 participants: midwives (n=16), obstetricians (n=8), assistant nurses (n=11) and managers (n=8). The text from interviews was analysed using content analysis.

FINDINGS

From expressing no explicit need of a midwifery model of woman-centred care before the intervention, there was a shift in midwives, obstetricians and managers perceptions towards identifying advantages of using the MiMo as it gives words to woman-centred midwifery care. Such shift in perception was not found among the assistant nurses.

DISCUSSION

Clarification of the various roles of health professionals is needed to develop the model. Heavy workloads and stress were barriers to implementing the model. Thus, more support is needed from organisational management.

CONCLUSIONS

The model was useful for all professional groups, except for assistant nurses. Further studies are needed in order to clarify the various professional roles and interdisciplinary collaborations in making the MiMo more useful in daily maternity care.

Women Give Birth and Pizzas Are Delivered: Language and Western Childbirth Paradigms

This article examines two differing health paradigms, their language, and their effect on the culture of Western childbirth practices. Specifically, the differences in perspectives and language between the dominant paradigm/culture (the biomedical model of curing) and the alternative paradigm/culture (a holistic model of caring) are explored. Examples of language from the medical, midwifery, and nursing literature that affect childbirth culture and the care of childbearing women and their families are examined. The use of language as a tool of power and its known and postulated effects on the childbirth experience, nursing care, midwifery practice, and holistic care are explored. The author argues for the use of a woman-centered paradigm for childbirth experiences.

A descriptive study of "being with woman" during labor and birth

The objective of this study was to learn more about women's perceptions of the nurse-midwifery practice of "being with woman" during childbirth. The descriptive, correlational design used a convenience sample of 238 low-risk postpartum women in a hospital nurse-midwifery practice, with two childbirth settings: a standard labor and delivery unit and an in-hospital birth center. The main outcome measure was a 29-item seven-response Likert scale questionnaire, the Positive Presence Index (PPI), administered to women cared for during labor and birth by nurse-midwives to measure the concept of being with woman. Statistical analysis demonstrated women who gave birth in the in-hospital birth center or who began labor in the in-hospital birth center prior to an indicated transfer to the standard labor and delivery unit gave higher PPI scores than women who were admitted to and gave birth on the standard labor and delivery unit. Parity, ethnicity, number of midwives attending, presence of personal support persons, length of labor, and pain relief medications were unrelated to PPI scores. Two coping/comfort techniques, music therapy and breathing, were found to be correlated with reported higher PPI scores than those of women who did not use the techniques. These results can be used to encourage continued use of midwifery care and for low client to midwife caseloads during childbirth, and to modify hospital settings to include more in-hospital birth centers.

A hermeneutic phenomenological analysis of midwives’ ways of knowing during childbirth

OBJECTIVE

to explore the ways of knowing used by the midwife while attending women during childbirth through textual analysis of poems written by American midwives.

DESIGN

a hermeneutic phenomenology and human science research method inspired by van Manen was used. Midwifery ways of knowing during childbirth were thematically derived from 10 poems written by midwives about attending childbirth or the experience of being a midwife. Textual analysis included examination of the poems as a whole, via verse and metaphor, and via individual lines of prose.

PARTICIPANTS

10 American midwives wrote the poems used in this study. The poems were discovered through online searches of many databases using the key words 'poetry, poems, midwifery and childbirth' and through a national call for poetry by the researcher over a period of 4 years (1996-2000), undertaken in order to publish an anthology of poetry written by midwives.

FINDINGS

three authoritative ways of knowing that guided the care given by the midwife to women during childbirth were discovered. They were self-knowledge from the belief system of the individual midwife, grounded knowledge from the midwife's personal lived experience with childbirth, and informed knowledge from objective and scholarly sources.

KEY CONCLUSIONS

midwives must continue to develop their own body of knowledge in order to move the profession forward. Multiple ways of knowing including the use of experiential/contextual and intuitive knowledge is legitimate and humane, if provision of care is holistic. Care of women during childbirth can be enhanced with the use of multiple knowers and multiple ways of knowing. This study captured a unique and fresh interpretation of the lived experience of midwifery knowledge. Midwifery educational programmes should offer opportunities for students to explore the artistry as well as the science of midwifery practice.

A description of Swedish midwives’ reflections on their experience of caring for teenage girls during pregnancy and childbirth

OBJECTIVE

to describe Swedish midwives' reflections on their experiences of caring for teenage girls during pregnancy and childbirth.

DESIGN

a hermeneutical approach was used, with focus-group discussions as the method of data collection.

SETTING

three focus-group discussions were conducted in a county comprising urban, suburban and rural districts in south-western Sweden.

PARTICIPANTS

a voluntary sample of 24 midwives, aged 32-61 years, who were caring for women in different birth settings, participated in 2004.

FINDINGS

two main themes, with three sub-themes each, were generated by the midwives: (1) the teenage mother, as 'teenagers who are proud of becoming mothers', 'teenagers who are unprepared for becoming mothers' and 'teenagers with an immigrant background', and (2) 'the midwives' wish to care for the teenage mother', as 'taking the teenage mother seriously', 'being an important person for the teenage mother', and 'being a help for the teenage mother'.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the findings provide some understanding of the unique characteristics of caring for teenage mothers. For the midwives, the most important aspects of caring for the teenage mother included taking the teenage mother seriously, allowing the midwife herself to become an important person for the teenage mother, and being a help to the mother. This help requires the midwife to balance the different needs of each teenage mother.

Central concepts in the midwife-woman relationship

The relationship between the midwife and the woman is essential for a positive experience for woman during childbearing period, i.e. pregnancy, childbirth and the first postpartum phase. Thereby, the aim of this study was to delineate central concepts in the midwife-woman relationship, in normal as well as high-risk situations. A secondary analysis was performed on original texts from eight Swedish qualitative studies, all with a phenomenological or phenomenological-hermeneutic approach. Six pairs of concepts were elucidated; each one describing one aspect from the woman's perspective and one responsive aspect from the midwife. The pairs of concepts are: surrender-availability, trust-mediation of trust, participation-mutuality, loneliness-confirmation, differenceness-support uniqueness and creation of meaning-support meaningfulness. Disciplinary concepts about the midwife-woman relationship have evolved that are essential for care in both normal and high-risk contexts, and we suggest that they should be implemented as a guide for midwifery care.

A midwifery model of care for childbearing women at high risk: genuine caring in caring for the genuine

According to this paper's synthesis of research, three constituents of ideal midwifery care emerge. First, a dignity-protective action takes place in a midwife's caring relationship with a childbearing woman at high risk and includes mutuality, trust, ongoing dialogue, enduring presence, and shared responsibility. Secondly, the midwife's embodied knowledge is based on genuineness to oneself and consists of theoretical, practical, intuitive, and reflective knowledge. Finally, nurse-midwives have a special responsibility to balance the natural and medical perspectives in the care of childbearing women at high risk, especially by promoting the woman's inborn capacity to be a mother and to give birth in a natural manner. This midwifery model of care is labeled "Genuine Caring in Caring for the Genuine." Here, the word genuine expresses the nature of midwifery care, as well as the nature of each pregnant woman being cared for as a unique individual.

New directions in midwifery education: the master's of science in midwifery degree

Midwifery is reclaiming its perspective as a discipline separate from, yet integrally related to nursing and medicine. Emerging trends in health care place increased demands on the knowledge base and clinical practice of midwifery, stimulating a need for new directions in midwifery education. The master's of science with a major in midwifery is a new degree option available to midwifery students in the United States. This article presents the argument that midwifery is a distinct discipline and describes the importance of a master's of science in midwifery degree toward furthering the work of the discipline of midwifery. Descriptions of the current master's of science in midwifery degree programs are included.

Competencies for midwifery teachers

Saving women's lives with cost-quality effective midwifery care is based on sound pre-service and ongoing education. Effective midwifery education requires competent, caring, and compassionate teachers. In this paper, I address the basic competencies required of midwives who teach others to be midwives. These competencies are important regardless of level of student taught, type of educational programme, or number of years of midwifery experience that learners bring to the educational setting. The competencies are based on the midwifery philosophy, values and model of care. Competent midwifery teachers must be competent midwifery clinicians for their primary role is to set the boundaries of safety for each level of learner. Formal preparation for teaching, understanding how adults learn, understanding how to develop an appropriate plan for learning (curriculum), and developing competency in a variety of teaching methods for both theory and clinical practice are included in the competencies discussed in this paper.

Outcomes of high-risk women cared for by certified nurse-midwives

This study describes the incidence of specific high-risk factors of a population cared for by a group of certified nurse-midwives (CNMs) in a Mid-Atlantic, inner-city, nonprofit, hospital-based clinic. Outcomes were compared with all women who delivered in the United States in 1994. Univariate statistics, which consisted of descriptive statistics, frequencies, and percentage distribution, were used. This comparison suggests that CNMs can provide safe care to women with high-risk conditions. Outcomes for the midwifery sample were more favorable for vaginal births, vaginal deliveries after cesarean section, forceps- and vacuum-assisted deliveries, cesarean delivery, and 5-minute Apgar scores. The incidence of maternal fever and meconium stained amniotic fluid was higher. Implications and limitations of the study are discussed.

Market orientation and professionalism: the case of nurse-midwives

Much has been written regarding the market orientation and professionalism constructs, but there is little work relating the two. Understanding the relationship between a market orientation and professionalism is of great relevance to the development and implementation of marketing programs in professional service organizations. Past research suggests that either a positive or a negative connection between these constructs could exist. However, a survey of certified nurse-midwives finds a fairly strong positive relationship between market orientation and professionalism.

A model of exemplary midwifery practice: results of a Delphi study

What is unique and exemplary about the midwifery model of care? Does exemplary midwifery care result in improved outcomes for the recipient(s) of that care? These are the questions that the profession of midwifery grapples with today within the context of a changing health care arena. Exemplary midwives, and women who had received their care, came to consensus about these issues in a Delphi study. A model of exemplary midwifery care is presented based on the identification of essential elements aligned within three dimensions: therapeutics, caring, and the profession of midwifery. Supporting the normalcy of pregnancy and birth, vigilance and attention to detail, and respecting the uniqueness of the woman, were several of many processes of care identified. The critical difference that emerged was the art of doing "nothing" well. By ensuring that normalcy continued through vigilant and attentive care, the midwives were content to foster the normal processes of labor and birth, intervening and using technology only when the individual situation required. Health care, whether in the gynecologic setting or during pregnancy, was geared to help the woman achieve a level of control of the process and outcome. The ultimate outcomes were optimal health in the given situation, and the experience of health care that is both respectful and empowering. The model provides structure for future research on the unique aspects of midwifery care to support its correlation with excellent outcomes and value in health care economics.

Middle range theory: spinning research and practice to create knowledge for the new millennium

The foundation of middle range theory reported during the past decade was described and analyzed. A CINAHL search revealed 22 middle range theories that met selected criteria. This foundation is a firm base for new millennium theorizing. Recommendations for future theorizing include: clear articulation of theory names and approaches for generating theories; clarification of concept linkages with inclusion of diagrammed models; deliberate attention to research-practice connections of theories; creation of theories in concert with the disciplinary perspective; and, movement of middle range theories to the front lines of nursing research and practice for further analysis, critique, and development.

Comfort in labor and midwifery art

PURPOSE

To examine the phenomenon of comfort in the context of childbirth. Enhancement of comfort for laboring women is a valued outcome of nursing and midwifery care. Interventions that increase comfort during labor support a woman's effort to participate more fully in the birth thereby keeping her more aware of her body, emotions, and experience.

ORGANIZING CONSTRUCT

The concept of comfort is analyzed and defined in the context of laboring women. Comfort studied from a feminist perspective is suggested.

SOURCES

A literature review of nursing, midwifery, and medical texts from the 1920s to 1998 provides information about labor, pain in labor, and goals of providers caring for laboring women. Research articles focusing on comfort are identified as they relate to the concept of comfort in labor. Writings of contemporary feminist authors provided the ideas for designing the study of comfort from a feminist perspective.

METHODS

To develop a theory of comfort during labor, early nursing and midwifery texts were searched to identify goals of care. The meaning of comfort was analyzed from the early 1920s to the present by concept analysis. Validation of findings was sought from publications on comfort research.

FINDINGS

Comfort can exist in spite of great pain and nurses and midwives may be able to assist laboring women to achieve a level of comfort during labor. Intervening to promote the comfort of laboring women can empower these women during birthing.

CONCLUSIONS

For clinicians caring for birthing women, particularly midwives, promotion of comfort is a high priority. Increasing comfort can redefine the meaning of pain in childbirth. Increasing comfort may create a decreased need for medical interventions and lower costs.

Methodological problems in the assessment of nurse-midwifery practice

Through a review of the past 30 years' literature that addresses the structure, process, and outcomes of nurse-midwifery care, the limitations inherent to the study of nurse-midwifery are identified. The need for a prospective study that represents the diversity of nurse-midwifery practice patterns and incorporates an appropriate control group is acknowledged. Difficulties inherent in the design and statistical analysis of such a study are discussed.